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nsurers Collected Billions From Medicare for Veterans Who Cost Them Almost Nothing Bruce Kitt is one of the Medicare Advantage industry’s most lucrative customers. The federal government pays his private Medicare Advantage insurer thousands of dollars a year to cover the cost of doctor visits, hospitalizations and other medical care that the 74-year-old retired aircraft mechanic might need. But Kitt, an Air Force veteran who served in Thailand during the Vietnam War, gets almost all of his healthcare outside the Medicare system, through the Minneapolis VA Medical Center. The taxpayer-funded Department of Veterans Affairs health system provides low-cost or free care to Kitt and about nine million other qualifying veterans. Kitt’s Medicare Advantage insurer, an affiliate of CVS Health’s Aetna unit, pays for almost nothing other than a $100 monthly cash-like rebate to Kitt as an incentive to keep him on its rolls. The government paid the insurer at least $6,000 to cover him in 2022, the year he joined the plan. “I don’t think I’ve used my Medicare in years,” said Kitt, who lives in Eden Prairie, Minn. When he needed some eye tests, the VA, not his Medicare Advantage plan, paid for him to go to an outside clinic. “I’m pretty happy with the VA,” he said. “I look at the Medicare plan as a backup.” Air Force veteran Bruce Kitt gets almost all of his healthcare outside the Medicare system, through the VA. Photo: Jenn Ackerman for The Wall Street Journal A Wall Street Journal analysis of Medicare and VA data found that Medicare Advantage insurers collected billions of dollars a year in premiums to provide medical coverage for about one million veterans like Kitt, even though they go to the VA for some or all of their healthcare needs. The analysis found the insurers paid far fewer medical bills for those veterans than for typical members. About one in five members of Medicare Advantage plans that enroll lots of veterans didn’t use a single Medicare service in 2021, the Journal found. That compares with 3.4% of members of other Medicare Advantage plans. The federal government paid insurers an estimated $44 billion from 2018 through 2021 to cover Medicare Advantage-plan members who were also users of VA services, based on average payments for all members of those plans. The VA spent $46 billion on the same group’s medical care, according to VA data reviewed by the Journal. The figures exclude pharmacy costs, which many Medicare Advantage plans focused on veterans don’t cover. Under the decades-old law that created Medicare, the VA can’t bill Medicare Advantage insurers for services it provides their members. The result is that the federal government sometimes effectively pays twice to cover the health needs of veterans—once in premiums for their Medicare Advantage insurers, then again for the VA to provide actual healthcare services. Some Medicare Advantage companies are openly chasing veterans, rebranding their insurance offerings with names like the Humana Honor plan, the Aetna Eagle plan and UnitedHealth Group’s Patriot plan. Almost all the veteran-branded plans offer cash rebates to induce veterans to sign up, a perk that is rare in other Medicare plans. “These private Medicare Advantage companies are taking large payments from the federal government but avoid paying for healthcare because the VA provides the services,” said Amal Trivedi, a physician at the Providence VA Medical Center and Brown University professor who has studied the VA-Medicare Advantage payment issue. Insurers said their plans offer veterans more choices for their healthcare, comply with Medicare rules and are priced to account for lower spending on veterans who also use the VA. They said veterans are heavy users of the extra benefits the plans offer, such as dental care, which isn’t reflected in the Journal analysis. The Minneapolis VA Medical Center, which takes care of most of Kitt’s medical needs. The VA health system provides low-cost or free care to about nine million qualifying veterans. Photo: Jenn Ackerman for WSJ A spokesman for Aetna, which insured Air Force veteran Kitt through its affiliate, said the company is proud to offer Medicare Advantage to veterans and complies with Medicare rules. The VA encourages veterans to sign up for some form of Medicare, even if they have access to VA health, in part because Medicare gives them the choice of going to a non-VA doctor or hospital. Medicare Advantage plans are attractive to many veterans because they offer perks that go beyond what Medicare requires, ranging from the dental benefits to gym memberships. Medicare Advantage, the privatized form of the federal health program for seniors and disabled people, was expanded about two decades ago in an effort to deliver care more efficiently. The insurers get paid a lump sum every month to cover members’ healthcare, with higher payments for patients diagnosed with more serious health conditions. The private plans now cover more than half of Medicare recipients. The program has proved popular, but also has cost taxpayers far more than traditional Medicare coverage, according to the Medicare Payment Advisory Commission, a congressional agency. One reason, the Journal has reported previously, is insurance company practices that result in higher payments from the government, such as diagnosing patients with conditions that no doctor had ever treated but that entitle insurers to billions of dollars in extra payments. To analyze how Medicare Advantage insurers can profit from veterans, the Journal examined 93 plans where a majority of members were veterans who used VA health services. The plans, covering about 200,000 people in 2021, were identified using VA data provided by Trivedi and his team at Brown and the Providence VA. The Journal then used Medicare data to examine how much the insurers were paid by the government for each plan, compared with how many medical services their members used. Under Medicare rules, the government payments are supposed to be based on the amount insurers expect to spend on members’ health expenses, plus an allowance for overhead and a modest profit. Each year, insurers propose pricing for their plans, which Medicare must approve. The Journal’s analysis suggests that the government is overpaying insurers for veterans’ coverage. The insurers charged the government a total of about $1.7 billion in 2021 for the veteran-majority plans. On a per-member basis, that came to 77% as much as other plans in the same geographic areas. The lower price, insurers say, reflects the lower cost of caring for veterans who are getting a portion of their care from the VA. But members of the veteran-majority plans used far fewer medical services than members of the other plans: They had 53% as many surgeries, 50% as many doctor visits and 55% as many radiology scans. They also spent fewer days in the hospital—about 72% as many as members of other plans. A Medicare spokeswoman said insurers’ prices “are expected to reflect the lower revenue need, given that veterans may access the VA for some services.” The biggest veteran-majority plan in 2021 was a Humana Honor plan that covered about 13,000 members in the upper Midwest. Three-quarters of the plan's members received medical services from the VA. Only 5% of members of other Medicare Advantage plans in that area used VA services. Medicare paid Humana an average of $7,702 per member of the Honor plan that year. That’s 78% as much as the federal government paid other Medicare Advantage insurers to cover members in the same area. But the Honor plan members spent far fewer days in the hospital than members of the other plans and had about one-third as many doctor visits, meaning lower costs for the insurer. A spokesman for Humana, the leader in veteran-focused Medicare Advantage plans, said veterans “have earned the right to choose their healthcare coverage” and that they benefit from the additional options. The spokesman, Kevin Smith, said Humana’s analysis of its own plans, which used a different methodology, “yields higher veteran utilization of Medicare Advantage benefits” than the Journal’s analysis. He also said the Journal’s analysis doesn’t account for veterans’ use of certain additional benefits offered by its plans, such as dental and vision coverage. The Medicare data was reviewed by the Journal under a research agreement with the federal government. The data don’t include patients’ names, but cover details of doctor visits, hospital stays and other care. The Journal didn’t use the data to identify patients named in this article. Investigating Medicare Insurers Pocketed $50 Billion From Medicare for Diseases No Doctor Treated The One-Hour Nurse Visits That Let Insurers Collect $15 Billion From Medicare Medicare’s Opioid Limits Didn’t Protect This Doctor’s Patients From Deadly Overdose The Sickest Patients Are Fleeing Private Medicare Plans—Costing Taxpayers Billions While members of veteran-majority plans used few Medicare-covered services, many were heavy users of VA health services, according to the VA data provided by Trivedi. The VA system spent an average of about $17,000 caring for veterans in those plans in 2021, not including pharmacy spending, about 30% more than the typical veteran. Total spending on all Medicare Advantage members amounted to 17% of the VA’s $100 billion healthcare expenditures in 2021, the VA data show. That’s a big dent for an agency that has struggled in recent years to meet demand, partly because of an influx of veterans seeking care after Congress expanded eligibility for VA health benefits. VA officials have asked Congress for extra funding to cover medical costs in the current fiscal year. Congress so far hasn’t acted on the request. Richard A. Stone, a retired Army major general and physician who ran the VA health system under parts of the Obama, Trump and Biden administrations, said top VA officials have long been aware that Medicare Advantage insurers were getting paid by the government to cover veterans who were receiving some or all of their care at the VA. They never addressed it, he said, because they worried that a fix lacked political support. There is a simple solution, he said: Congress could allow the VA to bill the Medicare Advantage insurers. When the VA treats younger veterans who have private insurance through their employers or the ACA marketplace, rather than Medicare, the agency sends a bill to their insurers for any care not connected to their military service. The VA collected $3.7 billion in 2024 from non-Medicare insurers from such claims, VA budget figures show. But the VA has been prohibited from billing Medicare—including Medicare Advantage insurers—since the program was created in 1965, decades before the private plans emerged as a dominant force in Medicare. When it comes to traditional Medicare patients, that doesn’t matter much because the government only pays once for their care, whether it’s through Medicare or the VA. “Nobody ever envisioned in 1965 a third party entity, like UnitedHealth or Humana, actually running the Medicare program on behalf of the federal government,” said Stone. “Bringing this to light will have huge value in the evolution of the Medicare program and for the health of veterans.” VA press secretary Terrence Hayes said in an email: “We will continue our efforts to collect all applicable revenue as part of our commitment to being good stewards of taxpayer funds and providing veterans, caregivers, family members, and survivors with the care and benefits they deserve.” The Humana spokesman said the company strongly supports increased coordination between Medicare and the VA, “given the aging population of veterans and increasing complexity of their healthcare needs.” Low-Cost Customers Many members of veteran-majority plans didn't use any Medicare services at all. Plans run by Humana, the leader in covering veterans, had the highest rates of non-use. Percentage of non-users by plan The VA generally receives high marks for delivering quality care. In addition to running hospitals and outpatient centers, the VA covers billions of dollars worth of care outside its own system because Congress requires it foot the bill when its own facilities can’t provide timely or convenient care. That means Medicare Advantage plans often avoid costs for veterans even when they go to private hospitals or doctors. Academic studies have identified the duplicate-payment issue, including a 2012 paper by Brown’s Trivedi and others. Researchers at the University of Pennsylvania in a 2020 study found the VA was picking up the tab for thousands of costly heart surgeries on Medicare Advantage members. A Harvard University-led research report in November found Medicare paid insurers $1.3 billion in 2020 for veterans who used no Medicare services. The extra benefits offered by many Medicare Advantage plans make them a “no-brainer” for a veteran who gets the majority of medical care from the VA, said Tim Jopp, an insurance broker in Waconia, Minn., who sells a lot of the veteran plans. Perks in the veteran-focused plans often include the cash-like rebates that insurers pay to encourage people to sign up and stay in. The rebates—discounts on Medicare premiums—show up as higher monthly payments in recipients’ Social Security checks. As of this year, 88% of plans marketed to veterans paid such rebates, compared with 11.7% of other plans. On average, members of veteran-branded plans were eligible for about $1,000 a year in such rebates, a Journal analysis of benefit and enrollment data shows. The Humana spokesman said many veteran-focused plans offer more extra benefits than other Medicare Advantage plans because they don’t usually cover pharmacy benefits. Plans that cover drugs typically spend some of their revenue available for extra benefits to subsidize pharmacy costs, he said. Humana, based in Louisville, Ky., covered 79% of all Medicare members who were in veteran-majority plans in 2021, the Journal analysis shows. The company rebranded some of its veteran-heavy plans as Honor plans in 2020, and told investors its Honor plans’ membership grew by 80% the next year. UnitedHealth Group, which launched its Patriot-branded plans aimed at veterans in 2021, markets some through senior advocacy group AARP. Under Medicare Advantage rules, insurers are entitled to extra payments from the government for patients with certain diagnoses. When customers go straight to the VA for care, though, their insurers might not be aware of such payment-boosting diagnoses. Another way for insurers to collect diagnoses that make them eligible for extra payments, including for conditions being treated only by the VA, is by sending nurses to visit members at their homes to gather health information. UnitedHealth dispatched nurses to conduct home visits with members of its veteran-majority plans about 20% more frequently than other UnitedHealth Medicare recipients in the same regions, the Journal analysis found. UnitedHealth said in a written statement that the company’s plans “ensure veterans have access to important additional benefits such as vision, dental, and hearing that complement their VA benefits.” Spokesman Matt Wiggin said veterans are heavy users of such benefits and that the Journal’s analysis was inaccurate because it didn’t account for use of such perks. Medicare data about plans’ projected spending on optional extra benefits isn’t available for 2021, the year the Journal studied, and Wiggin didn’t provide any for UnitedHealth’s plans. The company didn’t respond to a question about its home visits to veterans. Navy veteran John Burks, 72, of Wichita, Kan., said he signed up for a Humana Honor plan years ago, but for years never used it, preferring to get his healthcare from the nearby Robert J. Dole VA Medical Center. Navy veteran Burks, 72, said he didn’t turn to his Medicare Advantage insurance until last year, when he fell off a ladder. Burks get most of his healthcare from the Robert J. Dole VA Medical Center near his home in Wichita, Kan. Photo: Doug Barrett for WSJ “I get basically all of my care at the VA,” Burks said. “I’ve had excellent care there,” he said, despite what he described as sometimes long waits. That didn’t stop Humana from contacting him frequently, he said, asking to send a nurse for a home visit. “I told them, I just had my annual physical. Why do I need this?” But he allowed them to come three or four times over the years, he recalled. Burks, who said he enlisted in the Navy while still in high school, comes from a military family. He said his father was twice wounded in the Korean War, and his grandfather fought in World War I. Over the years, he said, he has been treated at the VA for a chronic lung disease, issues related to asbestos exposure from his Navy service and prostate cancer. He got hearing aids and eyeglasses from the VA, he said, which also paid for him to go to an outside provider for an operation on his nose, which he broke multiple times when he was younger. He never used Humana’s medical insurance to pay for any of it, he said, until last year, when he fell off a ladder. He stayed in a local hospital and a rehab facility for about six weeks and had multiple surgeries. The sizable bill was covered by Humana, he said, adding that “Humana has done me excellent, too.” The Humana spokesman said Burks’s experience shows how Medicare gives veterans the option to get care they need from non-VA doctors and hospitals. Shortly after being released in a wheelchair, Burks went to the VA emergency room with what he said was a hospital-acquired infection. Then he required six months of physical therapy—paid for by the VA. How the Journal Analyzed Medicare Data The Journal obtained Department of Veterans Affairs data covering 2018 to 2021 from a research team affiliated with the Providence VA Medical Center and Brown University. The data showed the number of users of VA services who also were enrolled in Medicare Advantage plans, along with VA spending data for those people. Using that data, the Journal identified 93 Medicare Advantage plans with a majority of members who used VA services in 2021. The Journal excluded plans with fewer than 50 enrollees. The Journal used Medicare plan-payment data to compare payments to insurers for covering members of those 93 plans to payments for covering members of other plans in the same geographical areas. The analysis compared usage rates of common Medicare services for those two groups, based on Medicare Advantage encounter data obtained under a research agreement with the federal government. The Journal weighted for the geographical distribution of the veteran-majority plans’ members and excluded less common plan types as well as so-called special-needs plans. The analysis excluded payments for drug coverage. The Journal identified members of each veteran-majority plan for whom insurers submitted no 2021 service records. The analysis compared the rates of such members in veteran-majority plans to the rate for all Medicare Advantage members. Graphics in this article are based on the Journal’s analysis, unless otherwise noted. LINK https://www.wsj.com/health/hea...ons-bfd47d27?mod=tre | ||
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| Thank you Very little  |
So the problem is that VA covered veterans are signing up for the MA plans, and, there is nothing in the law that prevents it from happening, and, there is no data matching between the VA, Medicare, and the MA insurers to reject them, since, there is no legal reason they can't enroll. MA insurers aren't going to fight it as it's profitable to have a VA vet on the rolls who make few claims, but doubt they know they are a Veteran going to the VA either since it's not a condition of enrollment as established by Medicare. | |||
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Calling DOGE… | |||
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| Get my pies outta the oven!  |
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