New analysis by the Center for Public Integrity of Medicare Advantage audits show that 35 of the 37 companies audited by the Centers for Medicare & Medicaid Services (CMS) overcharged the government by millions of dollars each year. By “upcoding” claims, insurance companies report patients as being sicker than they are and thus collect higher payments from Medicare.
By overstating the severity of medical conditions like diabetes and depression, extra payments are made to health plans which claimed some diabetic patients also had complications of the disease, such as eye or kidney problems. After the CMS audits, these claims were ultimately reduced or invalidated in nearly half the cases, sometimes more. This CPI report isn’t the first time private insurers in Medicare Advantage have come under fire. In May, a Government Accountability Office report called for “fundamental improvements” to curb excess charges linked to faulty risk scores. In addition, at least half a dozen health-industry insiders have filed whistleblower lawsuits that accuse Medicare Advantage insurers of manipulating risk scores to boost profits.
CPI also found:
Auditors on average could confirm just 60 percent of more than 20,000 medical conditions plans were paid to treat. The confirmation rates were much lower for some conditions, such as diabetes with serious complications, depression and some forms of cancer.
Overpayments triggered by unsupported medical diagnoses at the 37 plans audited topped $10,000 per patient for more than 150 patients. The health plans overcharged the government by $2,000 or more for at least 3,500 people in the 2007 sample group.
The health plans overall were three times as likely to charge Medicare too much as too little for some of the 70 medical conditions examined as part of the audits.
None of the plans faced closer scrutiny following the audits, no matter the size of the overpayment. The 2007 audits, which collected a total of $12 million in overpayments, are the only ones CMS has completed since officials adopted risk scores in 2004 at the behest of Congress. In some cases, health plans are still appealing the results, nine years later.
17 million seniors are enrolled in Medicare Advantage and in 2014, Medicare paid the health plans more than $160 billion. The Center for Public Integrity reported that overspending tied to inflated risk scores has cost taxpayers tens of billions of dollars in recent years.