Medicare Eligibility on the Rise – Along With FCA Claims

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Centers for Medicare Services (CMS) plays a major role in defining what constitutes acceptable medical care. As our population continues to age, and more Americans become Medicare eligible, the center’s influence will grow.

The Centers for Medicare Services

CMS (Medicare and Medicaid) currently pays over a trillion dollars a year for medical care, medication and medical devices and equipment. That is more money than most of us can comprehend.

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To put this in context, look at these conversions from minutes or seconds to years demonstrates the relative magnitude of CMS health care spending.

  • One million minutes is 1.9 years.
  •  One billion minutes is 1,900 years.
  •  One trillion minutes is 1,900,000 years.
  •  One trillion seconds is 31,700 years.

Health care is provided on behalf of individuals and paid to individuals on a service by service basis. The money is paid in relatively small amounts to a large number of providers for services provided to millions of recipients of benefits from CMS. Approximately 4.5 million claims are processed every day at CMS.

An Aging Population

The population in the United States is getting older. The baby boomer generation is rapidly approaching retirement age, and the age of Medicare eligibility. People are living longer, and will need additional medical care as they age. Approximately 10,000 new people enroll in Medicare every day. The government expects new enrollment to continue at that pace for the next 15 years. By 2035, 80 million Americans will be Medicare eligible, approximately twice the current number.

Today, CMS is spending $1 trillion a year. As the number of beneficiaries grows to the estimated 80 million, CMS will be paying around $8 trillion a year – if the current rate of $10,000 per beneficiary holds steady.

The government spends nearly $450,000 for each Medicare recipient. With 10,000 enrolling every day, the cost goes up quickly. CMS pays for care to bring the cost down to a more manageable number.

Dissatisfaction With CMS

Some changes have been implemented. Others are being delayed as a result of dissatisfaction with CMS proposals.

Many doctors do not accept Medicare or Medicaid reimbursement. Some common explanations are the delay between providing the service and being paid, the documentation required, and the perception CMS pays less for medical care than private insurers and individuals.

The proposed changes in reimbursement advocated by the government are viewed by many physicians and health care facilities as another way to pay less for the same services they already believe are under compensated.’

The legislature has repealed the Affordable Care Act. The congressional budget office estimates 24 million people will lose their insurance by 2026. Some should qualify for Medicaid if the law stays as it is drafted.

False Claims Act

The federal government has filed criminal, civil and administrative claims via the False Claim Act on health care services which were unauthorized, not performed or performed badly.

Between 2009 and the end of fiscal year 2015, the Office of the Inspector General recovered approximately $16 billion in settlements, judgments, fines and return of funds from providers. The government has also intervened in whistle blower lawsuits by individuals who sue on behalf of the government in return for a percentage of the money recovered. Barry E. Lewin

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