HHS OIG Says Medicare Advantage Plans Collected $6.7B in Improper Payments

A report from the U.S. Department of Health and Human Services' Office of Inspector General (OIG) suggests private insurers in the Medicare Advantage (MA) program may have improperly collected $6.7 billion in federal payments in 2017 by distorting enrollees' health conditions, reports Politico Pro . Medicare's risk adjustment scheme requires the government to pay higher rates to MA plans with sicker beneficiaries. The OIG determined insurers added diagnoses to enrollees' charts that doctors' records did not validate in over 99 percent of cases, and deleted diagnoses in less than 1 percent. The OIG added that if beneficiaries are as ill as the insurers' claim, then clinicians' own records are not indicating that they are receiving the necessary care. "This report is about process, not payments," argued Kristine Grow of America's Health Insurance Plans, noting the data from providers on enrollees' visits has been problematic, and insurers have been urging improvements to the system. Meanwhile, experts said insurers' enthusiasm for enlarging payments is built into MA's design. "The system incentivizes MA plans to work very hard to detect conditions that yield risk adjustment bumps, and so the MA plans work very hard to detect" such conditions, noted former Centers for Medicare and Medicaid Services official Michael Adelberg.