The Government Accountability Office, the watchdog arm of Congress, has sharply criticized CMS for its failure to ferret out overcharges and in April 2016 called for “fundamental improvements” in audits of Medicare Advantage plans. GAO also found that CMS has spent about $117 million on Medicare Advantage audits, but recouped just under $14 million overall.
Medicare Advantage plans have been the target of at least a half-dozen whistleblower lawsuits alleging patterns of overbilling and fraud. In March, the Justice Department joined one such suit against insurance giant UnitedHealth Group. The suit alleges that the health plan submitted claims for underpayments to the government, but ignored examples in which it had received too much money.
The audits disclosing the $128 million in overpayments to health plans were part of a cache of confidential CMS documents released through a Freedom of Information Act lawsuit filed by the Center for Public Integrity.
The CMS records identify the companies chosen for the initial Medicare Advantage audits as a Florida Humana plan, a Washington state subsidiary of United Healthcare called PacifiCare, an Aetna plan in New Jersey and an Independence Blue Cross plan in the Philadelphia area. The fifth one focused on a Lovelace Medicare plan in New Mexico, which has since been acquired by Blue Cross.
In the audits, CMS repeatedly found that the health plans couldn’t document their patients were as sick as the insurer had claimed.
For example, auditors couldn’t confirm that one-third of the diseases the health plans had been paid to treat actually existed, mostly because patient records lacked “sufficient documentation of a diagnosis.”
Overall, Medicare paid the wrong amount for nearly two-thirds of patients whose records were examined; all five plans were far more likely to charge too much than too little. For 1 in 5 patients, the overcharges were $5,000 or more for the year, according to the audits.
America’s Health Insurance Plans, an industry trade group, has denied that Medicare Advantage plans overcharge. The group argued in a June 2016 position paper that the auditing method used by CMS was “not yet stable and reliable.” The group also said that conducting audits “could disrupt the care being provided by plans that are working hard to meet the needs of their enrollees.”
Grassley cited reports by the Center for Public Integrity that improper payments to Medicare Advantage plans cost taxpayers as much as $70 billion from 2008 to 2013. He said that CMS’ estimate that it had overpaid the five health plans $128 million “appears low and could very well be just the tip of the iceberg.”
Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation. Schulte, formerly of the Center for Public Integrity, is now a senior correspondent at Kaiser Health News.
