EDITORIAL: Fighting for fraud [The Citizens' Voice, Wilkes-Barre, Pa.]

Citizens' Voice, The (Wilkes-Barre, PA)

Mar. 24—If overly expensive health care in the United States could be summarized in a single headline, this one from The New York Times would be a good candidate: "Biden Plan to Cut Billions in Medicare Fraud Ignites Lobbying Frenzy."

Yes, lobbyists for the health insurance industry have descended upon the Capitol to preserve the companies' ability to overbill the federal government by $25 billion a year.

Under Medicare Advantage, the government pays private insurers to provide coverage for older Americans. Companies get a flat rate for each enrollee and a bonus for each enrollee with qualifying serious conditions.

Federal audits, lawsuits, federal prosecutions and academic studies show a pattern by which insurers often submit the highest possible diagnostic codes to secure the bonus payments. Four of the five largest Medicare insurers face or have settled lawsuits alleging fraudulent up-billing.

The administration proposes to reduce the number of codes that insurers may use by about 20%, eliminating broad descriptions such as "diabetes with complications," to ensure that reimbursements cover actual specific diagnoses. In one of the federal lawsuits, an insurer's internal email described that diagnosis and a few others as "the golden nuggets we are looking for."

The industry has attempted to convince consumers that the administration is attacking Medicare rather than the industry's own fraud. Consumers and Congress should not buy it. And the administration should persist in accordance with a Department of Health and Human Services spokeswoman's promise that "we will not be deterred by industry hacks and deep-pocketed disinformation campaigns."