Federal Audits Of Medicare Advantage Reveal Widespread Overpayments

CMS Seems Loathe to Reveal the Data

MA-PLAN MEETINGV2Four Medicare Advantage audits were recently revealed courtesy of a Freedom of Information Act lawsuit filed by the Center for Public Integrity (CPI), adding to growing concern that yet more significant billing errors and inflated risk scores are contributing to millions in overpayments – this time, however, by the insurance plans, not the providers.

The audits and their data are not new, and appear to show the reason for the recent mounting scrutiny of Medicare Advantage plans and potential upcoding associated with beneficiary risk scores.

The four most recent audits targeted four insurance plans across the country, including Aetna Health Inc. (New Jersey), Independence Blue Cross (Philadelphia), Lovelace Health Plan (New Mexico), and Care Plus, a division of Humana Inc. (Florida). Another audit was revealed just last month, when CPI published an audit of UnitedHealth Group, showing that the plan overbilled $381,000 in a small sample of Medicare Advantage claims.

What the Audits Found

Artist's Concept of the Medicare Advantage Plans with CMS corrections applied.

Artist’s Concept of the Medicare Advantage Plans with CMS corrections applied.

Among the findings from the audits:

  • Medicare paid the wrong amount for 654 of the 1,005 patients in the sample, an error rate of nearly two-thirds. The payments were too high for 579 patients and too low for 75 of them. Total payment error for the sample: $3.3 million.[Note: Honestly, I’m quite surprised there was no extrapolation done.]
  • Auditors concluded that risk scores were too high for more than 80% of the patients, which in many cases, about 25%, led to hefty overpayments. Medicare’s annual payment for those patients were at least $5,000 higher per year.
  • Auditors could not confirm one-third of the 3,950 medical conditions the health plans reported, mostly because records lacked “sufficient documentation of a diagnosis.” In the reports however, the names of the medical conditions were redacted by federal officials.

Why All the Secrecy?

Why all the secrets about this? CMS is more than happy to share overpayment data for providers, so why do they literally HIDE the data about overpayments to insurance companies?

Why all the secrets about this? CMS is more than happy to share overpayment data for providers, so why do they literally HIDE the data about overpayments to insurance companies?

Despite recent attempts at “transparency” made by CMS – such as the data dumps concerning physician payments – the agency appears to be highly protective and secretive about data from the Medicare Advantage plans.

Two prominent U.S. senators on both sides of the aisle have expressed deep concern and have made it clear that they are actively looking into all the inconsistencies in the plans.

Earlier this year, Humana disclosed a justice department investigation into risk adjustments assigned to Medicare Advantage beneficiaries, adding that the government’s request for information was part of a “wider review of Medicare Risk Adjustment.” Since then, DaVita Healthcare revealed that it received a subpoena from the U.S. Department of Health and Human Services requesting Medicare Advantage documents dating back to Jan. 1, 2008.

 

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