Last week in my Medicare 101 class the “what-ifs” reared its ugly head. While going over the basics of Medicare I heard, “yeah, that’s great but what if this administration does this or “what if this administration does that” where will we be then?
Recently, these questions and concerns are voiced every day by current clients and new clients just aging-in to Medicare. “What if?”
My answer is, “I don’t have a crystal ball and can’t see into the future. So, I will continue to work with the programs we have until I am told something different. That’s all any of us can do.”
But I will not lie to you. I too have the “what-ifs” bouncing around my head every day.
There are three major social “entitlement” programs that are constantly referenced by Congress that could be affected in their search for the $880 billion in savings laid out in the budget resolution it passed earlier this month: Social Security, Medicare and Medicaid.
As recently as last week the White House sent out a statement reiterating the administration’s stance that Medicare and Social Security will not be touched.
So that leaves Medicaid. A social safety net that, as of November 2024, provided health insurance for 79 million Americans. Of which, 37.5 million are children under age 18.
Medicaid is a joint Federal and State run program to protect the most vulnerable among us. Those with low incomes (earning less than $1,800 a month), the young, disabled and the elderly unable to provide for themselves.
In the same time period, Medicare covered 68.5 million Americans, and 69 million Americans were receiving Social Security benefits.
So why is Medicaid being singled out and not the other two? If I were to venture a guess it’s because those of us on Medicare and drawing Social Security are more likely to vote then those who are indigent, disabled and especially the 37.5 million under voting age altogether.
Every administration comes into office on a pledge to purge the federal government of fraud, waste and abuse within the system. But this administration is going after the low hanging fruit by attacking those who need the help the most.
Cutting benefits from those who depend on them is cruel and far from the compassionate community we, I hope, still believe in. Don’t get me wrong. There most certainly is fraud, waste and abuse happening every day.
While both providers and beneficiaries can be involved in Medicaid fraud, providers are responsible for the majority of the monetary losses due to fraud, waste, and abuse not the beneficiaries. This is often due to billing for services not provided, “upcoding” procedures, or other fraudulent activities.
Every year I must take a Medicare/Medicaid course on fraud, waste and abuse. In the course there are real life examples of providers who often engage in schemes like billing for services not rendered, submitting duplicate claims, or falsely claiming they provided more services than they actually did.
While less common, beneficiaries can also commit fraud, such as selling prescription drugs or using another person’s Medicaid card.
Instead of stripping benefits from those who need it, the federal government needs to root out fraud, waste and abuse in both Medicare and Medicaid. In Fiscal Year 2024, the estimated cost of fraud, waste, and abuse in Medicare and Medicaid programs was approximately $100 billion. This figure represents improper payments made in these programs, which include errors, mistakes, and potentially fraudulent activities.
According to the Center for Medicare and Medicaid Services (CMS) here’s the breakdown:
Medicare:
• The Medicare Fee-for-Service (FFS) improper payment rate was 7.66%, resulting in an estimated $31.70 billion in improper payments.
• The Medicare Advantage (MA) improper payment rate was 5.61%, totaling $19.07 billion.
• The Medicare Part D improper payment rate was 3.70%, with $3.58 billion in improper payments.
Medicaid:
• The overall Medicaid improper payment rate was 5.09%, or $31.10 billion.
• A significant portion (79.11%) of these improper payments were due to insufficient documentation, not necessarily fraud.
The real culprit isn’t “those” people. It’s a system that fails to actively close the loopholes that allow the schemers to scheme. If we do a better job in stopping fraud, waste and abuse we make the programs sustainable and protect those we need to protect.
Next Medicare 101 class is on May 29 @ 6pm at Traverse District Library in TC.