OIG: Medicare overpaid millions for Part C enrollees

Medicare overpaid more than $26 million to Medicare Advantage organizations between 2010 and 2012 for 1,591 people not lawfully-present in the United States, according to an Office of Inspector General performance audit report.

Specifically, the Centers for Medicare & Medicaid Services didn't share unlawful presence information with MA organizations because the agency lacked procedures to do so. Without these data, payers couldn't prevent more than 31,000 mistaken enrollments, the report states.

In a related prior study, the OIG assessed a similar overpayment of $91.6 million under Parts A and B for unlawfully-present beneficiaries.

MA organizations must accept enrollment requests received from beneficiaries regardless of whether requests arrive in interviews or by mail, fax or other means defined by CMS, according to a commentary by former U.S. Department of Health & Human Services Inspector General Richard P. Kusserow. In light of CMS information, the MA must respond to the request within 10 calendar days of its receipt with an enrollment acknowledgement, a request for more information or a denial notice.    

People must be American citizens, U.S. nationals or aliens lawfully-present in the United States to qualify for Medicare benefits. Federal law generally prohibits payment of federal public benefits, including health insurance benefits such as Medicare Advantage, on behalf of unlawfully-present aliens, the report states.

The OIG found inconsistent internal control of this problem for Parts A, B and C. Unlike Medicare Advantage, CMS implemented procedures to prevent and detect Medicare fee-for-service payments for ineligible beneficiaries. Auditors found 10 unlawfully-present beneficiaries for whom CMS denied fee-for-service claims payment; but CMS let the same people enroll in Medicare Advantage later, according to the report.

The OIG recommended three corrective actions for CMS: Recoup the overpayments, implement procedures to share unlawful presence data with MA organizations, and continue identifying and recovering improper payments until Medicare no longer pays for unlawfully-present beneficiaries.

For more:
- here's the OIG report (.pdf)
- read Kusserow's commentary

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