Newly released Medicare Advantage audits show some plans overbilled upward of $1K per patient each year

Newly released audits show Medicare Advantage plans overbilled the federal government by millions between 2011 and 2013, with some plans overbilling an average of more than $1,000 per patient per year, Kaiser Health News reported Nov. 21. 

CMS released the decade-old audits in response to a lawsuit from the news outlet. 

The 90 plan audits uncovered $12 million in net overpayments for the 18,090 patients sampled. CMS has said it plans to use these error rates to recoup an estimated $650 million in repayments, KHN reported. 

The agency has yet to recover these payments several years after the original audits. CMS said it would release a final rule to extrapolate repayment amounts from the audit, but moved the decision to February. 

Of the 90 plans audited, 71 were found to have overbilled the government. Twenty-three of these plans had overpayments exceeding an average of $1,000 per patient. For the remaining audits, the agency found it had underpaid plans. 

UnitedHealthcare and Humana plans accounted for 26 of the 90 audits. UnitedHealth had eight audits that found overpayments, while seven found it had been underpaid by CMS. Of the 11 Humana audits, 10 found overpayments exceeding $1,000 per patient on average, KHN reported. 

Payers are facing allegations they have exploited Medicare Advantage by making patients appear sicker than they are, thereby receiving more reimbursements from the government. 

Nearly every major payer has been accused of or settled allegations of Medicare Advantage fraud, according to recent reporting from The New York Times.

Read more about the audits here.  

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