Medicare Advantage Overcharges In the Millions, Audit Reveals
(IntegrityPress.org) – Medicare has become one of the most controversial topics of discussion in healthcare since it was first introduced by President Lyndon B. Johnson in 1965. Advocates say it’s a step toward accessible, affordable healthcare for all Americans, while detractors call it an inefficient and costly taxpayer burden. A recent audit shows that some insurance companies have continually overcharged the federal government for Medicare payments to the tune of millions of dollars.
How It Happened and How It Came to Light
A Freedom of Information Act (FOIA) lawsuit submitted by Kaiser Health News (KHN) against the Centers for Medicare & Medicaid Services (CMS) in 2019 led to the emergence of this story. The request uncovered the results of 90 federal agency audits of Medicare Advantage plans between 2011 to 2013. These reviews, which covered a mere fraction of all Medicare Advantage contracts nationally, revealed net overpayments of approximately $12 million by the federal government in the years concerned.
Overcharging occurs when insurance companies claim patients are sicker than they are. The CMS audits showed that insurers frequently couldn’t provide proof of certain diagnoses they claimed patients had when submitting their Medicare Advantage billing.
According to the audits, United Healthcare and Humana were among the worst offenders. The pair are also the biggest insurers in the Medicare Advantage program.
Where Do We Go From Here?
These audits cover just three years of Medicare Advantage’s lifespan; the intervening nine years have likely involved overcharging on a much greater scale. Reports from various government officials and leaks from industry whistleblowers have repeatedly indicated that miscalculations of this type have cost the federal government billions of dollars.
A number of experts in the field recommend government intervention. Some suggest that Medicare Advantage audits should use extrapolation to determine how much money the government has overpaid, similar to Medicare audits. Others state more stringent and widespread auditing of Medicare Advantage plans may be the answer.
The government may have an uphill battle ahead of it in the fight to obtain refunds for past overpayments. Some legal experts believe it would be unfair to demand that companies fork over the funds after so many years have gone by, while others feel these organizations and businesses should be held accountable. Ultimately, companies may be able to protect themselves from the expense via litigation anyway.
Do you think this story is indicative of a broader problem of inefficiency in the Medicare program? If so, how do you think the federal government should address this issue?
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