FOIA lawsuit uncovers audits showing 35 health plans overbilled Medicare Advantage

Joseph Burns

About Joseph Burns

Joseph Burns (@jburns18), a Massachusetts-based independent journalist, is AHCJ’s topic leader on health insurance. He welcomes questions and suggestions on insurance resources and tip sheets at joseph@healthjournalism.org.

Fred Schulte

A federal review of health insurers operating Medicare Advantage plans shows that 35 health plans overbilled the federal Centers for Medicare & Medicaid Services, the Center for Public Integrity reported on August 29.

Fred Schulte, a CPI senior reporter, said the center obtained 37 MA plan audits through a Freedom of Information Act lawsuit. The documents indicated that 35 of those health plans were overpaid in 2007. The typical overpayment was several hundred thousand dollars.

“Among the insurers charging the government too much: five Humana, Inc. health plans, three UnitedHealth Care Group plans and four Wellpoint, Inc. plans,” Schulte wrote. None of the plans would comment for Schulte’s article.

This is the second time we’ve reported that government auditors confirmed the work that Schulte and other CPI reporters in their 2014 series, The Medicare Advantage Money Grab. In that investigation, CPI reported that overspending tied to inflated risk scores had cost taxpayers tens of billions of dollars in recent years.

In May we wrote about a Government Accountability Office report calling for reforms to stop health plans from overbilling CMS using upcoding that employed faulty risk scores.

Last week we posted a Shared Wisdom item from Schulte about how to cover this complex issue. Schulte included a link to a CMS report, Medicare Advantage Risk Adjustment Data Validation Audits Fact Sheet (pdf), that discussed audits the agency is doing on insurers running MA plans. The fact sheet would be a good starting point for journalists covering health plan audits.

Earlier this month, Erica Teichert reported in Modern Healthcare that a MA plan  whistle-blower case against Aetna, Health Net, UnitedHealthcare and WellPoint could proceed. The insurers were alleged to have submitted false data to CMS to support payments for their MA patients.

The whistleblower, James Swoben, accused the companies of conducting biased retrospective medical record reviews to certify their use of risk adjustment data for MA payments.

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