Fraud Case Casts Spotlight on Medicare Advantage Plans

As privately run Medicare health plans for seniors scramble to stave off proposed funding cuts, federal prosecutors in Florida are pursuing an unusual criminal fraud case that’s likely to raise new concerns that some plans may be overcharging the government. The criminal case is believed to be among the first to take aim at billing practices of Medicare Advantage plans, which are popular with seniors because out-of-pocket costs are lower and they provide more benefits than traditional Medicare. The case centers on a South Florida doctor affiliated with Humana Inc., one of the industry’s biggest players. A federal grand jury in West Palm Beach, Fla., indicted the doctor, Isaac Kojo Anakwah Thompson, on eight counts of health care fraud on Feb. 4. He’s accused of cheating Medicare out of about $2.1 million by claiming his Humana-enrolled patients were sicker than they actually were. Thompson, 55, was arrested and is free on a $1 million bond. Through his lawyer, he declined comment. The indictment does not accuse Humana of wrongdoing. Company spokesman Tom Noland said in an email that the Louisville, Ky.-based insurer is “cooperating fully with the authorities.” He said Thompson was never employed by the company and is “no longer a participating physician with Humana.” Still, the case is likely to draw heightened scrutiny to potential billing fraud and abuse in Medicare Advantage as well as questions about the effectiveness of government oversight of the fast-growing industry, which costs taxpayers more than $150 billion a year. The Florida indictment comes as the industry mounts a major advocacy and public relations offensive in Washington to stave off proposed budget cuts. The Centers for Medicare and Medicaid Services, or CMS, is set to propose rates that the health plans will be paid next year, on Feb. 20. The Obama administration’s 2016 budget seeks to cut some $36 billion from Medicare Advantage plans over the next decade related to risk scores.

Source/more: National Public Radio