20 insurers received half of $9.2B in suspicious Medicare payments, feds report

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A new HHS Office of Inspector General report details that 20 insurers received about half of a $9.2 billion pool of suspicious Medicare payments made over the course of a year. 

The office conducted the investigation after citing concerns over how Medicare Advantage payers could game the system to claim more funds by abusing chart reviews and health risk assessments for risk-adjusted payments, according to the report.

The report pointed to 20 companies that made up a "disproportionate" share of the $9.2 billion pot, especially compared to the other 142 payers who claimed questionable funds. The 20 companies collectively received 54 percent of payments, totaling to $5 billion. 

Of the 20 companies, one had 40 percent of the risk-adjusted payments from chart reviews and HRAs, but only maintained 22 percent of Medicare Advantage beneficiaries. This accounted for $3.7 billion of the total questionable payments. 

The unnamed outlier company made standout use of HRAs, and almost all of them were conducted in-home, according to the report. 

The report encourages CMS to provide additional oversight on the 20 companies in question, with additional scrutiny and actions to judge the appropriateness of the one outlier company's payments and care.

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