This bipartisan proposal is a logical step to improve Medicare solvency

The federal Medicare health insurance program for seniors has been overbudget since its inception in 1965. By 1990, the plan was at least nine times over the original budget as determined by the Congressional Budget Office (CBO).

Eliminating waste, fraud, and abuse in the program would seem to be a noncontroversial first step to decrease the financial burden on taxpayers and guarantee that future generations of seniors have access to Medicare.

A bipartisan bill, The No UPCODE Act, has been proposed in the United States Senate to address fraudulent upcoding in the Medicare Advantage or Medicare Part C program. Senate Finance Committee Chairman Mike Crapo (Idaho), along with other Senate Republican and Democratic colleagues, is on record in support of the bill.

Special interest groups, however, have lobbied strongly against the bill, arguing that the proposal would lead to Medicare “cuts.” The bill is currently stalled in the U.S. Senate. The CBO estimates that passage of the bill would save taxpayers $124 billion over ten years.

Medicare is divided into four parts: Part A is for hospital coverage, Part B is for provider payments, Part D is for drug benefits, and Part C or Advantage is essentially a health maintenance organization (HMO) that includes additional benefits, such as eye and dental care, at a fixed price. Medicare Advantage has been the fastest-growing segment of Medicare over the past ten years or so and is an alternative to Parts A and B.

Parts A and B are considered traditional Medicare, which basically allows enrollees to go to any hospital or provider. Advantage, on the other hand, is set up such that participating health insurance companies receive one check from the federal government for all advertised benefits. Enrollees have a co-pay, but the insurance company requires them to go to “approved” hospitals and providers that have contracts with the insurance company.

Historically, competition among health insurance companies involved in the Medicare Advantage program has been fierce. Even conservative pundits and political leaders have supported Medicare Part C because of the perceived competition. Yet, regardless of the amount, taxpayers are still making the basic payments to the insurance companies before patients pay their co-pay.

Traditional HMOs are set up such that enrolled patients pay their entire insurance premium. The HMOs can and do save money by denying or delaying patient care. Medicare Advantage (essentially an HMO), on the other hand, allows participating insurance companies to receive more taxpayer money if their enrolled patients are sicker. Hence, companies will add questionable or unnecessary diagnoses to patients’ health records, which leads to fraudulent upcoding.

Since over half of all Medicare recipients are enrolled in Medicare Advantage, eliminating upcoding would be an excellent first step to saving taxpayer money in the overall Medicare program.

Not only would this reform save money, it would also be a start at guaranteeing the viability of Medicare for seniors in the future. Ending the practice of fraudulent upcoding is a logical step to improve Medicare solvency, and Congress should give this proposal serious consideration.