Four ways to protect yourself from Medicare Advantage fraud liability

Medicare Advantage plan sponsors could be facing a greater level of scrutiny, and potentially more legal costs, but legal experts say four simple steps could potentially mitigate liability.

Merle DeLance and Lyndsay Gorton, with Dickstein Shapiros LLP's Government Contracts Practice, coauthored an article in Managed Care Magazine, addressing some of the fraud liability concerns surrounding managed care plans. Over the last several months, more whistleblower lawsuits have surfaced, citing concerns over inflated patient risk scores, which could leave payers on the hook for additional legal costs and potentially more oversight and enforcement actions from the Centers for Medicare & Medicaid Services (CMS), including civil monetary penalties or payment suspensions.

In light of these new risks, DeLance and Gorton recommended plan sponsors take the following four "protective steps":

  • Understand the laws pertaining to fraud and false claims
  • Ensure accurate and complete billing information, since documentation will be key to defending any fraud allegations
  • Implement a compliance program that can oversee Medicare Advantage plans
  • Report any abuse or violations promptly to save on litigation costs

Over the past several months, Medicare Advantage risk scores have emerged as a key fraud concern, with experts estimating that inflated scores have cost the program $2 billion annually. In addition to recent whistleblower lawsuits, secret government audits have found millions in potential overpayments tied to inflated risk scores.

Furthermore, two senators on both sides of the aisle have called on the Department of Justice (DOJ) to investigate fraud and abuse tied to Medicare Advantage plans. In its 2016 Work Plan, the Office of the Inspector General indicated that it would continue targeted audits of managed care plans, including Medicare Advantage.

To learn more:
- read the Managed Care Magazine article