Medicare Advantage won't be out of federal watchdogs' sights anytime soon.
John Kelly, attorney and chair of Barnes & Thornburg’s healthcare department and industry practice, told Becker's the federal government is cracking down on fraud across healthcare, including Medicare, Medicaid and Medicare Advantage.
The enforcement agencies, whistleblowers and attorneys involved in investigating and prosecuting MA fraud are all becoming more sophisticated, Mr. Kelly said.
"You have a lot of different things coming together that are drawing unwanted attention to Medicare Advantage and creating a lot of enforcement and oversight," he said.
Medicare Advantage is growing rapidly. The program now accounts for more than half of Medicare beneficiaries. More taxpayer dollars flowing to Medicare Advantage brings more government scrutiny, Jacquelyn Papish, a partner at Barnes & Thornburg specializing in healthcare fraud, waste and abuse, told Becker's.
"Understandably, the government is turning its eye toward the program and making sure the money is flowing in the right direction and for the right reasons," Ms. Papish said.
The federal government has investigated several payers for intentional upcoding — making patients appear sicker than they are on paper to receive more reimbursement from the government.
Upcoding reentered the spotlight in July, when the Wall Street Journal published an investigation that found between 2018 and 2021, insurers received $50 billion diagnoses they added to members' charts. Many of these diagnoses were "questionable," according to the investigation.
Risk-adjustment audits conducted by HHS' Office of Inspector General can offer insights into what watchdogs are keying in on, and what specific risk adjustment codes are of interest to auditors, Ms. Papish said.
"The number reported by the Wall Street Journal is extremely significant. I think it's something that everybody in the industry is paying attention to now," Ms. Papish said.
AHIP, the trade association representing health insurers, called the WSJ report "flawed, incomplete and outdated" in a July 8 statement.
"Constant education and involvement" for physicians and Medicare Advantage organizations to stay compliant, Mr. Kelly said.
"There's nothing wrong with using risk-adjustment codes, it's just got to be accurate," he said. "It's got to be supported in the medical record."
The Department of Justice could crack down on Medicare Advantage fraud through criminal enforcement, Mr. Kelly said.
In October 2023, the Department of Justice brought criminal charges against a former executive at Elevance Health-owned HealthSun Health Plans, alleging she orchestrated a scheme to submit false and fraudulent information to CMS.
"The criminal [enforcement] is coming. We're just starting to see that little by little, and that usually means there's more down the road," he said.
Though a new administration will lead the federal government in 2025, cracking down on fraud is likely to be a bipartisan priority, Mr. Kelly and Ms. Papish both said.
A new administration could choose to be less aggressive in pursuing fraud cases, Mr. Kelly said, but the government is obligated to review every whistleblower case identifying fraud.
"I think healthcare fraud enforcement tends to survive administrations," Mr. Kelly said.