Five things to know:
1. Federal officials know some Medicare Advantage insurers are overcharging the government through elevated risk scores that exaggerate how sick patients are. While CMS officials have routinely postponed or taken the brakes off efforts to collect the money, they are again attempting to recoup payments.
2. CMS proposed a series of audits aimed at collecting $1 billion in overpayments from Medicare Advantage insurers by 2020. The latest proposal would extrapolate error rates found in a random sample of 200 patients, according to NPR.
3. The extrapolation is expected to lead to many multimillion-dollar penalties. The technique is common in other medical fraud investigations, but the Medicare Advantage industry has successfully challenged and avoided the method.
4. CMS told NPR it has already conducted 90 of the enhanced audits for payments made in 2011-13 and anticipates collecting $650 million in penalties. That’s a significant increase from previous audits that have clawed back about $14 million total.
5. In 2019, CMS will begin audits for 2014-15, targeting roughly 5 percent of the 600 plans each year. America’s Health Insurance Plans, the industry’s trade group, has called on CMS to not use extrapolation on the audits for 2011-2013.
Read the full report here.
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