|Federal investigators identify $9.2bn in questionable Medicare payments|
Medicare insurers drew $9.2bn in federal payments in one year through controversial billing practices, with 20 companies benefiting disproportionately and together accounting for more than half of the total, according to federal health investigators. The findings by the Office of Inspector General of the Department of Health and Human Services are the latest sign of growing scrutiny of Medicare Advantage (MA) insurers, which offer private plans under the federal benefit program. Among the 20 companies flagged in the report, the investigators found that one received approximately 40% of the questionable payments, or $3.7bn, while enrolling only 22% of Medicare Advantage customers. The report didn’t name the company. At the heart of the investigation were the ways insurers in the Medicare Advantage program document diagnoses for enrollees. The payments the companies receive from the federal government are tied to the health status of their customers. Patients with more, and more serious, diagnoses generally draw higher payments for the health plans. The HHS inspector general’s investigation focused on two controversial strategies used by Medicare Advantage companies to tally diagnoses. In one, the insurers or their contractors review patients’ charts for evidence of diagnoses that doctors didn’t specifically flag. The other involves health-risk assessments, or HRAs, that are often conducted by the vendors in patients’ homes. Both strategies are allowed under Medicare rules, but “our findings raise concerns about the extent to which certain MA companies may have inappropriately leveraged both chart reviews and HRAs to maximize risk-adjusted payments,” the report said.