The Government Accountability Office is calling for "fundamental improvements" in CMS' effort to recover improper payments to private Medicare Advantage plans.
In a congressional audit released Monday, the GAO urged federal officials to curb overbilling by health plans, which were paid about $160 billion in 2014. CMS estimates that about 9.5 percent of its payments to Medicare Advantage plans were improper, according to the most recent data — primarily stemming from unsupported diagnoses submitted by Medicare Advantage organizations.
The GAO criticized Risk Adjustment Data Validation audits, which is how CMS recovers improper payments in the Medicare Advantage program. The GAO said CMS has spent about $117 million on these audits, but so far has recouped just $14 million, according to a Center for Public Integrity report. According to the report, CMS officials, however, said the mere threat of RADV audits has caused health plans to voluntarily return approximately $650 million in overpayments — and that upcoming audits will recover tens of millions more.
The GAO launched its audit in October 2014 amid the Center for Public Integrity's "Medicare Advantage Money Grab" series, according to the report. The articles documented nearly $70 billion in "improper" payments to health plans from 2008 through 2013 alone.
The GAO said CMS is stepping up the RADV audits, but added that improvements still need to be made, according to the Center for Public Integrity. GAO noted that officials expect the upcoming audits to recover $370 million, but that's just 3 percent of the total estimated annual overpayment.
CMS officials said they have begun auditing Medicare Advantage payments from 2011 and 2012 and have set a goal to have all Medicare Advantage contracts audited yearly.
"HHS is strongly committed to program integrity in the Medicare Advantage program and takes seriously our responsibility to protect taxpayer dollars by identifying and correcting improper payments," the agency said, according to the Center for Public Integrity.
More articles on finance and revenue cycle management:
What is drawing Cleveland Clinic, Mayo Clinic and other AMCs to Florida?
Opponents come out against proposal to charge Ohio Medicaid enrollees
For-profit hospital stock report: Week of May 2-6