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Government audits reveal millions in Medicare Advantage overpayments

Health experts say CMS secrecy inhibits research into overpayment concerns

Four more secret Medicare Advantage audits surfaced Friday thanks to a Freedom of Information Act lawsuit filed by the Center for Public Integrity (CPI). The most recent government audits add to the growing concern that significant billing errors and inflated risk scores contribute to millions in overpayments.

The audits target four different insurance plans across the country, including Aetna Health Inc., in New Jersey, Independence Blue Cross in Philadelphia, Lovelace Health Plan in New Mexico and Care Plus, a division of Humana Inc. in South Florida. Last month, CPI released a secret audit that found UnitedHealth Group overbilled $381,000 in a small sample of Medicare Advantage claims.

The newly released documents add to mounting scrutiny of Medicare Advantage plans and potential upcoding associated with beneficiary risk scores. The government reviewed claims of 201 patients from each of the five plans during 2007 and found that Medicare overpaid for more than half of the patients, totaling $3.3 million. Additionally, more than 800 of the 1,005 patients reviewed had inflated risk scores, and Medicare overpaid at least $5,000 each year for more than 200 of those patients. Experts recently estimated that inflated risk scores cost the government $2 billion each year.  

Health experts and researchers lamented the secrecy of the audits, and the unwillingness of the Centers for Medicare & Medicaid Services to release data associated with Medicare Advantage plans, particularly in light of the huge data dumps tied to physician payments over the last two years.

"Without the ability to answer these questions, we can keep pointing out how big the overpayment to MA (Medicare Advantage) is, but we can never really provide the optimal solution to the problem," Harvard Medical School researcher Timothy Layton told CPI.

Medicare Advantage overpayments have already drawn the ire of two prominent U.S. senators on both sides of the aisle. It's clear that federal investigators are also eyeing inconsistancies with Medicare Advantage plans. Earlier this year, Humana disclosed a justice department investigation into risk adjustments assigned to Medicare Advantage beneficiaries, adding that the government's request for information was part of a "wider review of Medicare Risk Adjustment." Since then, DaVita Healthcare revealed that it received a subpoena from the U.S. Department of Health and Human Services requesting Medicare Advantage documents dating back to Jan. 1, 2008.

For more:
- read the CPI report

Related Articles:
Government audit reveals UnitedHealth Group Medicare Advantage plan overbilling
Second senator calls for Medicare Advantage oversight
Humana says it's not alone in DOJ investigation of Medicare Advantage billing
New estimates say Medicare Advantage inflated risk scores cost $2 billion a year
Following $450 million settlement, DaVita subpoenaed for Medicare Advantage coding
Amid billions in recoveries, Medicare Advantage problems still linger