The Disadvantage of Medicare Advantage

This article serves as a critical exposé on the practices of insurance companies administering Medicare Advantage (MA) plans, detailing corruption and schemes that undermine the system. A major concern is "upcoding," where insurers deliberately add bogus or more complex, highly reimbursed diagnoses to patient records to extract significantly higher payments from the federal government, often for conditions the patient was never treated for. This fraudulent practice, incentivized by the 2003 Modernization Act which rewarded higher reimbursement for sicker members, leads to ridiculous discrepancies in complex diagnosis prevalence compared to traditional Medicare. The author recounts a personal experience where their MA company offered a physician house call—a tactic used to generate false complex diagnoses for higher revenue. Beyond financial fraud, MA companies engage in "cherry-picking," employing tactics like holding seminars in venues without elevators to discourage sick, high-cost seniors from enrolling. They also cancel policies of the sickest members and even pay nursing homes bonuses to limit expensive hospital transfers for acutely sick residents. While many seniors choose MA, the system relies on cumbersome preauthorization processes that frequently deny necessary, expensive procedures, impacting patient care and potentially affecting future chiropractic managed care contracts.