The Centers for Medicare & Medicaid Services released the results of 90 audits of Medicare Advantage plans. The federal audits discovered $12 million in net overpayments for the care of 18,090 patients sampled, Kaiser Health News reported Monday.
CMS released the audits to settle a Freedom of Information lawsuit KHN filed against the agency just over three years ago. The audits looked at billings from 2011 through 2013, which are the most recent reviews completed, according to KHN.
Currently 46% of Medicare-eligible older adults are enrolled in MA plans. That number is expected to exceed 50% within the next few years.
“It’s incredibly frustrating that it took a lawsuit and years of pushing to make this vital information public,” Thomas Burke, a San Francisco attorney who represented KHN pro bono, said in an article published on KHN’s website last month.
Medicare Advantage plans primarily are run by major insurance companies. As the plans have grown in popularity as an alternative to traditional Medicare coverage, they have fallen under increased scrutiny, as previously reported by McKnight’s. Last spring, the Office of Inspector General accused MA organizations of denying or delaying services that met Medicare coverage and MA billing rules. In August, CMS published a request for information, asking the public to provide input regarding various aspects of MA plans. Several home care organizations, including the National Association for Home Care and Hospice and the Partnership for Quality Home Healthcare, urged CMS to ensure that MA plans provide the same level of care as fee-for-service plans and release patients from hospitals to home healthcare in a timely fashion.
According to KHN, federal regulators have said they intend to extrapolate the payment error rates from those samples across the total membership of each plan — and recoup an estimated $650 million as a result. The audits go back more than a decade, yet there has been no attempt to recover the losses. CMS was set to unveil a final extrapolation rule Nov. 1, but that didn’t happen. The agency has now pushed that action off until February.
“I think CMS fell down on the job on this,” Ted Doolittle, a former deputy director of CMS’ Center for Program Integrity, told KHN, adding that “CMS appears to be ‘carrying water’ for the insurance industry, which is ‘making money hand over fist’ off Medicare Advantage.’”
In an email response to written questions posed by KHN, Dara Corrigan, a CMS deputy administrator, said the agency hasn’t told health plans how much they owe because the calculations “have not been finalized,” the news service reported.