CMS investigating healthcare providers for steering possible Medicare enrollees to higher-paying exchange plans
The federal agency is considering fines and other sanctions for providers who engage in this.
The Centers for Medicare and Medicaid Services is investigating whether some healthcare providers are steering consumers away from Medicare and Medicaid benefits and towards marketplace plans to get the higher reimbursement rates.
CMS is especially concerned about third-party premium provider and affiliated organization payments, the agency said Thursday. It has sent letters to all Medicare-enrolled dialysis facilities and centers informing them of its request for public comment on these concerns.
It is considering allowing issuers to limit their payment to Medicare-based amounts for particular services and care, CMS said.
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CMS is also considering potential regulatory and operational options to prohibit or limit premium payments, and the possible implementation of fine or other sanctions.
CMS said it is focused on situations in which there is a disruption in care as a result of changes to a patient's network provider. It is looking at authorities to impose fines on these providers when their actions result in late enrollment penalties for Medicare eligible individuals who are delayed in enrolling, the agency said.
The CMS Center for Program Integrity did not say how many providers or third-party affiliated organizations it believes are guilty of the practice.
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"We are concerned about reports that some organizations may be engaging in enrollment activities that put their profit margins ahead of their patients' needs," said CMS Acting Administrator Andy Slavitt.
Currently, third-party payment of premiums and cost sharing of qualified health plans in the individual market by healthcare providers such as physicians, medical facilities or affiliated nonprofit organizations are discouraged, but the ultimate decision about accepting those payments is left to health insurance companies.
Twitter: @SusanJMorse
