Medicare Advantage Overbilling Persists

The Government Accountability Office is calling for “fundamental improvements” in CMS’ effort to recover improper payments to private Medicare Advantage plans.(Becker’s Hospital CFO)

A scathing new report by the Government Accountability Office found Medicare is doing little to effectively prevent overbilling by private Medicare Advantage plans serving the elderly. (Healthcare DIVE)

The Center’s investigation traced the overpayments to abuse of a billing formula called a risk score, which pays higher rates for sicker patients and less for people in good health. Since 2004, however, the risk score formula has largely operated as an honor system, despite criticism that many health plans have overstated how sick some patients are to boost their revenues. That practice is known in medical circles as “upcoding.”(NPR)

Government audits of 201 patient records from each of five health plans released last year found upcoding in 80 percent of cases. And an investigation by the Center for Public Integrity found that upcoding accounted for nearly $70 billion in additional payments to Medicare Advantage plans from 2008 through 2013. (The New York Times)

Medicare officials have quietly conducted these audits since 2008. But they have never imposed stiff financial penalties even as evidence built up that billing errors were deeply rooted and wasting tax dollars at an alarming clip. (The Center for Public Integrity)

What is Medicare Advantage?