CMS to Investigate Improper Steering of Medicare, Medicaid Patients to ACA Plans

The Centers for Medicare & Medicaid Services recently released a statement requesting information from the public regarding the practice of providers or third-party organizations improperly steering Medicare- and/or Medicaid-eligible patients into ACA Marketplace insurance plans in order to accrue higher reimbursement payments, according to a press release.

The investigation comes after previous lawsuits by insurers claimed that provider-associated organizations intentionally steered patients into higher-cost, private insurance plans. Insurers stated that this process negatively impacts the ACA risk pool by unnecessarily taking on the cost burden of patients that should be covered under government programs.

“We are concerned about reports that some organizations may be engaging in enrollment activities that put their profit margins ahead of their patients’ needs,” Andy Slavitt, CMS acting administrator said in the press release. “These actions can limit benefits for those who need them, potentially result in greater costs to patients, and ultimately increase the cost of Marketplace coverage for everyone.”
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CMS also sent warning letters to all Medicare-enrolled dialysis centers, informing them of the investigation.

According to the press release, CMS is considering regulatory and operational measures to restrict or minimize the amount of premium payments. CMS is also currently exploring ways to penalize health care providers who engage in improperly steering Medicare-eligible patients away from government-based insurance programs. In the open letter, CMS further stated that knowingly selling Medicare-participating patients insurance benefits that are already covered is punishable by imprisonment under the Social Security Act.

CMS also noted that steering Medicare-eligible patients towards ACA market plans can often result in late-enrollment penalties for the patient, due to unnecessary delays. CMS plans to pass these penalties on to the providers responsible for steering these patients.

Patients who are steered away from Medicare coverage may also experience disruptions in care, changes to prescription benefits, changes to provider networks, and loss of dental coverage, according to the open letter.

“It is improper to influence people away from Medicare or Medicaid coverage for the purpose of financial gain,” Shantanu Agrawal, MD, CMS deputy administrator and director of the Center for Program Integrity, said in the press release. “Our goal is to protect patients from being unduly influenced in their decisions about their health insurance options, and to protect the integrity of all the programs we oversee.” —David Costill

The Centers for Medicare & Medicaid Services. CMS examines inappropriate steering of people eligible for Medicare or Medicaid into Marketplace plans. Cms.gov. Published August 18, 2016. Accessed August 19, 2016.