CMS agrees to release audit results of potential overcharges under Medicare Advantage plans
CMS officials say they expect to collect more than $600 million in overpayments from the audits.
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The Centers for Medicare & Medicaid Services has agreed to make 90 audits of private Medicare Advantage health plans public, which are expected to reveal hundreds of millions of dollars in overcharges to the government. Kaiser Health News sued the agency in the fall of 2019, alleging a violation of the Freedom of Information Act.
“It’s incredibly frustrating that it took a lawsuit and years of pushing to make this vital information public,” says Thomas Burke, a San Francisco attorney who represented the plaintiff. “Transparency — on a real-time basis — should be the norm for the public to have oversight of this multibillion-dollar, taxpayer-paid program.”
Under the settlement, CMS agreed to pay $63,000 in legal fees to the law firm and to “make its best efforts” to provide the documents over six weeks. In making the payment, the agency did not admit wrongfully withholding the records.
Bruce Alexander, director of the CMS Office of Communications, says the agency “is committed to safeguarding taxpayer dollars and strengthening program integrity in our operations.” CMS has sent the first round of records to Kaiser Health News and will provide additional records “in accordance with the terms of the settlement agreement,” he says.
Kaiser Health News filed the suit in U.S. District Court in San Francisco to obtain audits conducted for 2011, 2012 and 2013. CMS officials say they expect to collect more than $600 million in overpayments from the audits. The agency has disclosed the names of the health plans under scrutiny but no other details.
Read more: Almost half of eligible Medicare beneficiaries use Medicare Advantage, analysis shows
The cache of federal audits and other documents should provide the most extensive look to date at a secretive government auditing program known as Risk Adjustment Data Validation, according to Kaiser Health News. The audit program has struggled to prevent Medicare Advantage health plans from overcharging the government. These audits check medical records to make sure patients actually have the diseases that health plans are being paid to treat. Past audits have shown that Medicare Advantage plans often cannot document these claims.
CMS is expected to decide how to compute final overpayment amounts later this year. The industry has long opposed the audits, arguing the sampling methods are flawed, even though they are widely used in other types of Medicare audits.