PSA - If you enroll in Medicare Advantage, you could be stuck for life

[Celerity]

74. which conclusions?

I seldom disagree with you folks, but you may have good points, but your conclusions are bullshit

OIG audit targets Aetna’s Medicare Advantage plans as government cracks down on fraud

https://www.healthcaredive.com/news/oig-audit-targets-aetnas-medicare-advantage-plans-as-government-cracks-dow/604515/

Aug. 5, 2021



Dive Insight:

The federal government regularly audits health plans to ensure they comply with CMS regulations and aren’t gaming the system to secure higher payments. CMS pays plans on a per-member basis, then adjusts payments based on the acuity or severity of their member’s health status, as supported by provider data like diagnostic codes.

Typically, the sicker a member is, the higher the plan’s reimbursement. But as MA plans have grown to now cover more than 40% of all Medicare beneficiaries, so too has fraud and abuse. A 2020 OIG report found that MA paid $2.6 billion a year for diagnoses unrelated to any clinical services.

That’s resulted in the government stepping up its efforts to review and audit providers’ medical records to make sure they support the diagnostic codes that determine patients’ health status — and the resulting risk-adjusted premium payments to insurers.

Roughly a year ago, following a whistleblower complaint, the Department of Justice sued Cigna, alleging it falsified its MA members’ health statuses to nab an extra $1.4 billion in overpayments from CMS. Similarly, in April an OIG audit led the government to find Humana had overcharged CMS by almost $200 million using inaccurate documentation.

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