Though the government overpaid about $32 billion as a result of Medicare Advantage risk score errors from 2008 to 2010, federal officials didn't recover most of that money, according to the Center for Public Integrity, a nonpartisan investigative news organization.
Government audits performed four years ago found six insurers couldn't justify payments for at least 40 percent of their Medicare Advantage customers in 2007. Medical records lacked evidence that beneficiaries were as sick as payers indicated. Insurers apparently inflated risk scores to qualify for higher reimbursement or couldn't document diseases claimed, the CPI reported.
The risk score is a reimbursement tool that pays Medicare Advantage contractors more for sicker beneficiaries and less for healthy ones.
One audited insurer, for example, collected payment for someone with brain cancer when medical records contained no evidence that he had this problem. Per the records, the man received treatment for an enlarged prostate. This is a common condition that doesn't merit extra payment, the article noted.
This issue has stayed under the radar because government officials kept most risk adjustment data validation audit findings confidential, the article noted; but the CPI filed a lawsuit last month to get the results and see whom the government overpaid by how much, as FierceHealthPayer reported.
Despite the volume of program dollars on the line, the U.S. Department of Health and Human Services inspector general didn't conduct any more risk score verification audits and in 2013 put the brakes on future projects of this type due to a budget cut. Without such auditing, it's unlikely the public will know how Medicare Advantage plans draw out and spend taxpayer funds, the CPI reported.
"The billing system has failed and needs to be rejiggered," Patrick Burns, a co-director of Taxpayers Against Fraud, told the CPI. "Even when we catch it, nobody gets spanked."
Burns also told the CPI federal officials must protect programs from being "outgamed" by health insurers. "You need an electric fence for those cows," Burns said. "As soon as you touch it you get nailed."
- here's the CPI article