CMS to release Medicare Advantage audits in response to lawsuit

CMS will release 90 audits of Medicare Advantage plans accused of overcharging the government in response to a lawsuit from Kaiser Health News, the outlet said Oct. 14. 

In July 2019, Kaiser Health News reporters requested risk adjustment audits CMS conducted of Medicare Advantage plans in 2011, 2012 and 2013, according to court documents. In September 2019, the outlet filed a lawsuit alleging CMS had violated the Freedom of Information Act by withholding the documents. 

To settle the lawsuit, CMS will pay $63,000 in legal fees and "make its best efforts" to provide the Risk Adjustment Data Validation audit spreadsheets over the next six weeks. The overpayment amounts will be redacted from spreadsheets, Kaiser Health News said. 

In settling the lawsuit, the CMS does not admit wrongdoing. 

The agency said it expected to receive $600 million in overpayments from the audits. 

CMS previously released the names of plans being audited. 

Multiple payers — including UnitedHealth Group, Elevance Health, Cigna and SCAN Group — have been accused of using schemes to secure risk adjustment overpayments from CMS by the federal government, The New York Times reported Oct. 8. 

According to the Times, payers have engaged in tactics such as urging physicians to add extra illnesses to medical records and directing employees to look through records to find more illnesses. 

Kaiser Health News said the documents from CMS should be the "most extensive look to date" at the auditing practices used to detect overpayments. 

"Transparency — on a real-time basis — should be the norm for the public to have oversight of this multibillion-dollar, taxpayer-paid program," said David Burke, an attorney representing Kaiser Health News in the lawsuit.

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