GAO calls for 'fundamental improvements' to Medicare Advantage auditing

The government's leading watchdog agency called on the Centers for Medicare & Medicaid Services (CMS) to make "fundamental improvements" to its Medicare Advantage (MA) auditing process, which has been plagued with inefficiencies and recovered only a small percentage of estimated improper payments, according to a report released on Tuesday.

The Government Accountability Office (GAO) focused on risk adjustment data validation (RADV) audits designed to root out unsupported beneficiary diagnoses. The agency determined that the audit methodology fails to capture health plans with the highest risk for improper payments.The audits have also been met with substantial delays thanks to an inoperable medical record collection system and undefined timeframes for completing medical record reviews or finalizing appeals. Despite spending $117 million on these audits since 2010, CMS has recovered just $14 million in improper payments.

In December, CMS submitted a request for information to incorporate recovery audit contractors into the RADV program, five years past the deadline outlined by the Affordable Care Act. But GAO noted that the agency has no specific plans or timetable for that transition.

The GAO recommended CMS modify RADV audits to target high risk plans, improve the timeliness of the audit process and develop a timetable for integrating RAC audits.

Previously unreleased government records have shown CMS officials knew the agency was overpaying billions of dollars to MA plans, but still held back on auditing plands they dubbed "high-flyers." Some experts have said inflated risk scores account for as much as $2 billion each year, leading to at least half a dozen whistleblower lawsuits last year.

To learn more:
- here's the GAO report

Suggested Articles

The HHS OIG is asking for an additional $23.7 million to support fraud oversight that has benefited from an emphasis on data analytics.

A New York surgeon was sentenced to 13 years in prison for fraud and more physician practice news from around the web.

A federal judge has ruled that the U.S. government’s remaining fraud case against UnitedHealth can move forward.