Feds ramp up Medicare Advantage scrutiny

The federal government is ramping up scrutiny of Medicare Advantage plans. 

In October, the Cigna Group reached a $172 million settlement with the federal government to resolve allegations that it violated the False Claims Act by submitting incorrect Medicare Advantage patient data to CMS to receive higher payments from the agency.

HHS' Office of the Inspector General has audited several health plans in recent months for overpayments, estimating a Humana subsidiary received $117 million in overpayments in 2015. 

Melissa James, a senior consultant for health language at Wolters Kluwer, told Becker's government scrutiny of Medicare Advantage plans is "absolutely" increasing. 

"There's lots of evidence for that. The rate and types of audits are increasing. CMS will very soon be rolling out their new [risk adjustment data validation] audits. More so than that, we have OIG, that is continuing to add work plan projects pretty much every month that are targeting different types of scenarios they're going to be looking at," Ms. James said. 

Earlier this year CMS finalized tougher auditing standards for MA plans, striking the fee-for-service adjuster, which allowed a permissible level of payment errors and limited audit recoveries to payment errors above that level. The new clawback rule was opposed by the industry, and one insurer, Humana, is challenging the rule in court. 

Ms. James said these tougher standards will likely move ahead in 2024, despite the court challenges. 

"To be prepared for these RADV audits is paramount for [plans]. They need to have dedicated teams that could respond to any type of regulatory audit, RADV, OIG, etc., that are well-versed, educated and experienced in this space in order to handle and respond to the audits," Ms. James said. 

Beyond compliance audits and settlements, at least one plan executive is facing criminal charges for alleged Medicare Advantage fraud. 

In October, the Justice Department brought charges against Kenia Valle Boza, former executive of Elevance-owned HealthSun Health Plans, for allegedly orchestrating a multimillion-dollar Medicare fraud scheme.

Ms. Boza allegedly entered diagnoses into the medical records of beneficiaries enrolled in HealthSun's plans based on diagnostic tests that were not a proper basis for diagnosing those codes. 

Ms. Boza and others also allegedly obtained some physicians' login credentials to wrongfully access electronic medical records and fraudulently enter chronic conditions directly into the medical records of beneficiaries. The conditions were entered into beneficiaries' medical records often days or weeks after the physician saw the patient.

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