Feds investigating provider payments directing patients to ACA plans


The federal government is investigating whether certain healthcare providers are steering patients away from Medicare and Medicaid plans and toward Affordable Care Act coverage in order to boost reimbursement.

In a Request for Information, the Centers for Medicare & Medicaid Services says it is seeking more information on “anecdotal reports” that providers are paying premiums in order to direct Medicare- or Medicaid-eligible beneficiaries toward individual marketplace plans with higher reimbursement rates. Authorities said this practice could lead to higher overall healthcare costs and negatively impact the marketplace risk pool by funneling sicker patients into exchange plans.

“We are concerned about reports that some organizations may be engaging in enrollment activities that put their profit margins ahead of their patients’ needs,” CMS Acting Administrator Andy Slavitt said in an announcement. “These actions can limit benefits for those who need them, potentially result in greater costs to patients, and ultimately increase the cost of Marketplace coverage for everyone.”

The feds are zeroing in on dialysis providers in particular. In a letter to Medicare-enrolled dialysis centers, CMS indicated that it may impose civil monetary penalties against providers that “induce Medicare eligible individuals to delay/forgo Medicare enrollment if the Medicare eligible individual is later penalized for delayed enrollment.” CMS is also exploring new regulations to prohibit providers from making premium payments and allow insurers to reimburse certain services at the Medicare rate.

The Department of Health and Human Service initially discouraged providers from providing premium payments or cost-sharing support for individuals with ACA plans, but later clarified that insurers must accept third-party payments from private charitable foundations, state and federal programs, and grantees.

CMS' probe comes more than a month after UnitedHealth Group filed a lawsuit alleging American Renal Holdings Inc. “systematically” recruited patients with kidney disease and paid their premiums to bill as much as $4,000 for each dialysis session to UnitedHealth’s commercial plans.

- read the CMS RFI
- here’s the press release
- read CMS’s letter to dialysis providers