Mehmet Oz breathlessly touted private Medicare plans on his popular daytime TV show and in the years that followed. On Friday, the former surgeon pledged with equal enthusiasm to crack down on widespread fraud within the program.
The most specific policy idea Oz floated was to limit the number of procedures that are subject to prior authorization in Medicare Advantage to 1,000 and to use automation to speed up the prior authorization process. Currently, he said about 15,000 procedures and prescriptions must be pre-approved in the program. The pre-approval process is expensive and it wastes time, Oz said.
Oz cited reports from the Medicare Payment Advisory Commission, a group of Medicare experts that advises Congress, showing that Medicare Advantage is indeed more expensive. He said that's partly because of upcoding, where the government pays insurers more because they tack additional codes onto patients that make them seem sicker.
He cited the example of an insurer visiting a Medicare Advantage patient's home and diagnosing them with plaque in their arteries even if there's no treatment provided.
But insurers have abused risk adjustment for more than a decade and have tried to prevent the government from auditing them. They are incentivized to capture more diagnoses — and potentially exaggerate or even fabricate how sick someone is — to get more money.
The most specific policy idea Oz floated was to limit the number of procedures that are subject to prior authorization in Medicare Advantage to 1,000 and to use automation to speed up the prior authorization process. Currently, he said about 15,000 procedures and prescriptions must be pre-approved in the program. The pre-approval process is expensive and it wastes time, Oz said.
Oz cited reports from the Medicare Payment Advisory Commission, a group of Medicare experts that advises Congress, showing that Medicare Advantage is indeed more expensive. He said that's partly because of upcoding, where the government pays insurers more because they tack additional codes onto patients that make them seem sicker.
He cited the example of an insurer visiting a Medicare Advantage patient's home and diagnosing them with plaque in their arteries even if there's no treatment provided.
But insurers have abused risk adjustment for more than a decade and have tried to prevent the government from auditing them. They are incentivized to capture more diagnoses — and potentially exaggerate or even fabricate how sick someone is — to get more money.
Dr. Oz pledges Medicare Advantage scrutiny: 'There is a new sheriff in town'
Oz mentioned risk coding and prior authorizations as areas he plans to examine in Medicare Advantage.
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