- The new audit schedule from the Office of Inspector General will target Medicare Advantage plans and other managed-care plans sold under the Affordable Care Act, according to the agency's 2015 workplan.
- With Medicare Advantage plans, the feds are specifically targeting risk inflation. The sicker the patient, the more money the Centers for Medicare and Medicaid Services pays, creating an incentive for insurers to exaggerate the poor health of their beneficiaries. In an audit of six health plans in 2012, the OIG found that the insurers couldn't provide support for payments for 40% of their beneficiaries.
- Still, despite acknowledging millions of dollars worth of waste in the system, the feds aren't sure how much of the blame lies with deliberate fraud and how much with documentation errors, says Richard Kronick, director of Health and Human Services' Agency for Healthcare Research and Quality.
The agency has also announced healthcare reform-related audits that will look at "emerging vulnerabilities," such as those stemming from inaccurate subsidy payments and fraudulent enrollment. Probably a good idea, given that undercover investigators from the Government Office of Accountability recently used fictitious identities to apply for coverage and subsidies; Of the 12 false individuals, all but one were able to acquire and retain coverage.
Want to read more? You may enjoy this story on a recent OCR staff briefing to providers on what to expect when Phase 2 audits begin.