Feds look closely at Medicare Advantage plans in risk adjustment probe
Are Medicare Advantage overpayments driven by inflated risk scores?
Insurers with Medicare Advantage health plans are facing more public and government scrutiny over just how sick their senior members really are.
Insurers with Medicare Advantage health plans are facing more public and government scrutiny over just how sick their senior members really are.
Late February is Medicare Advantage regulatory proposal season, with health insurers waiting on the Centers for Medicare & Medicaid Services to propose the next year’s reimbursement schedule and new benefit and ratings rules. The Affordable Care Act-mandated rate changes are expected to continue bringing Medicare Advantage payments in parity with fee-for-service.
Unexpected, though, are new government probes into potentially inflated risk scores of Medicare Advantage beneficiaries and resultant over-reimbursement.
Humana, the second-largest Medicare Advantage insurer with 3 million senior members, has disclosed that the Justice Department is looking into allegations of improper risk adjustment.
[See also: MA plans on chopping block.]
“We continue to cooperate with and voluntarily respond to the information requests from the Department of Justice and the U.S. Attorney’s Office,” Humana wrote in its latest Securities and Exchange Commission filing.
The information requests are related to oversight and submission of risk adjustment data by Humana’s network providers, including two related to pending whistleblower lawsuits.
In the case has been unsealed, Olivia Graves, MD, alleges that her medical clinic was induced by Humana to add diagnostic codes to the insurer’s Medicare Advantage members’ medical records indicating erroneously the patients had diseases like diabetes or kidney disease.
The lawsuit is still pending, and Humana is not the only Medicare Advantage insurer to face scrutiny as the program enters a new period of growth.
Nearly one third of all Medicare beneficiaries, some 16 million seniors, are enrolled in the Medicare Advantage program, and annual costs are approaching $150 billion, increasing the potential for overpayments and scrutiny from watchdog groups and regulators.
The Center for Public Integrity is suing the Department of Health and Human Services to obtain a variety of oversight and investigation documents related to risk scoring for numerous Medicare Advantage plans, after the group’s Freedom of Information Act requests have languished for more than a year.
