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MEDICAL YEAR
IN REVIEW

Medicare Disadvantaged:

A Raft of Lawsuits Exposes Fraud in Medicare Part C

By John J. LoCurto, JD

H ealthcare fraud is a massive and stubborn problem. Perhaps major health insurance companies – e.g., Kaiser Permanente, United-

the best way to confirm this is to examine the annual Health
Health, Anthem – that allegedly bilked Medicare Advantage out of
Care Fraud and Abuse Control Program Report that the
United States Departments of Justice and Health and Human Services billions. To understand how fraud this big could have occurred, one
must first understand Medicare Part C.
prepare. Year after year, the Report touts huge fraud recoveries. In Fiscal Medicare Advantage is an alternative to traditional Medicare, which
Year 2021, it boasted healthcare fraud judgments and settlements ex- comprises inpatient (Part A) and outpatient (Part B) services. Under
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ceeding $5 billion and total collections approaching $2 billion. Of Part C, private health plans (MA Plans) contract with CMS to cover
course, recoveries that big necessitate even bigger frauds. Medicare beneficiaries who have opted out of traditional Medicare.
Schemes directed at Medicare Part C – also known as Medicare Ad- MA Plans must cover all the services that beneficiaries would normally
vantage – are an emerging concern. Losses are difficult to calculate pre- receive from traditional Medicare. Most plans also cover Medicare Part
cisely but are surely in the billions. The Centers for Medicare & D (prescription drugs) and many offer additional coverages not avail-
Medicaid Services (CMS) estimates that Part C overpaid more than able under traditional Medicare, including vision, hearing and dental,
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$15 billion in FY21. Other estimates range from $12 to $25 billion. 3 to attract beneficiaries. Enrollment in Medicare Advantage has ex-
With so much money at stake, it should come as no surprise that the ploded. According to the Kaiser Family Foundation, as of 2022,
Department of Justice designated Medicare Advantage an enforcement Medicare Advantage plans cover nearly 50% of the Medicare-eligible
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priority. The Department has filed or joined a raft of lawsuits against population – over 28 million persons.

24 SAN ANTONIO MEDICINE • December 2022