Dive Brief:
- The release of more than three dozen Risk Adjustment Data Validation (RADV) audits on Medicare Advantage plans shows nearly all of the audited plans (35 of 37) to have overcharged the federal government for most of the elderly patients they treated, according to a report by the Center for Public Integrity.
- Many of the never-before publicized audits from 2007, which were obtained by CPI researchers through a Freedom of Information Act lawsuit, are still being appealed.
- The controversy centers on the potential abuse of risk scores, which are used to calculate how sick patients are and what rates Medicare Advantage plans are therefore paid for their care.
Dive Insight:
The studies add fuel to the fire over ongoing allegations that some insurers have been inflating patient risk scores via "upcoding" to draw higher payments, costing taxpayers tens of billions in overspending on these plans.
CMS has previously stated that reducing improper payments in Medicare Advantage is a top priority, while CPI researchers have long argued that despite mounting evidence of the practice, federal officials have allowed the auditing program to fall short and let audits and appeals languish for years. The new report has added in May, a Government Accountability Office report called for a solution to the matter of faulty risk scores, and that at least half a dozen industry insiders have filed whistleblower lawsuits regarding manipulation of risk scores.
Some of the insurers found to have overcharged the government -- none of which provided comment to the CPI -- included five Humana plans, three UnitedHealth plans and four Wellpoint plans. The two plans found to have no net overpayments were Group Health Cooperative in Washington state and a Kaiser Foundation Health Plan in California.
The overpayments for unsupported medical diagnoses exceeded $10,000 per patient for more than 150 patients across the 37 audits, the researchers found, adding the health plans overcharged by $2,000 or more per patient for at least 3,500 people in the sample.
In another key finding, auditors found health plans three times more likely to charge Medicare too much than too little for certain medical conditions examined under the audits.
Meanwhile, Medicare Advantage plans have long challenged the RADV audit process, with Clare Krusing of America's Health Insurance Plans calling it "not yet stable and reliable" and arguing CMS doesn't allow health plans to submit additional supporting data regarding patients' conditions.