Sen. Chuck Grassley calls DOJ, CMS to task on Medicare Advantage payments

Sen. Chuck Grassley (R-Iowa) wants to know how the Department of Justice (DOJ) and the Centers for Medicare & Medicaid Services (CMS) are addressing the billing problems that have plagued Medicare Advantage for years.

Grassley, the chairman of the Senate Judiciary Committee, sent a letter to the DOJ and a letter to CMS to ask, among other things, how the two agencies are cooperating to investigate risk score fraud, which has cost CMS more than $70 billion in improper payments since 2008, according to NPR and the Center for Public Integrity.

Under Medicare Advantage, insurers receive higher reimbursements for treating patients with higher risk scores, as these patients tend to be sicker and therefore need more medical services. CMS has admitted than plans inflate risk scores to boost their payments, NPR said; the agency also said it struggles to rein in this type of fraud.

"With the reported increase in risk score gaming, and the monumental cost that the taxpayer will shoulder for such wrongdoing, it is imperative that CMS implement safeguards to reduce risk score fraud, waste and abuse," Grassley wrote in both letters.

Specifically, Grassley asked the DOJ for a "detailed explanation" of the steps it takes to ensure that insurance companies do not fraudulently alter risk scores, along with information about the number of risk score fraud investigations the department has conducted in the last five years.

The Senator seeks similar information from CMS. In addition, Grassley asked for the value of overcharge found in each audit conducted since the inception of Medicaid Advantage, as well as the amount of money that CMS allocates to audit Medicare Advantage fraud, waste and abuse.

At least six whistleblower lawsuits allege overpayments to Medicare Advantage plans, FierceHealthPayer: AntiFraud previously reported. Legal experts say many more cases may be coming.

For more:
- read Grassley's letters to the DOJ (.pdf) and CMS (.pdf)
- read the NPR and Center for Public Integrity article

Related Articles:
More whistleblower lawsuits target Medicare Advantage plans
Medicare Advantage overpayments top $70B
Amid billions in recoveries, Medicare Advantage problems still linger
Feds overlook billions in Medicare Advantage overpayments
The Medicare Advantage risk score debacle

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