Medicare failed to recover up to $125 million in overpayments, records show – news – the ledger – lakeland, fl

Six years ago, federal health officials were confident they could save taxpayers hundreds of millions of dollars annually by auditing private Medicare Advantage insurance plans that allegedly overcharged the government for medical services.

An initial round of audits found that Medicare had potentially overpaid five of the health plans $128 million in 2007 alone, according to confidential government documents released recently in response to a public records request and lawsuit.

But officials never recovered most of that money.


Database engine tuning advisor Under intense pressure from the health insurance industry, the Centers for Medicare and Medicaid Services quietly backed off their repayment demands and settled the audits in 2012 for just under $3.4 million — shortchanging taxpayers by up to $125 million in possible overcharges just for 2007.

Medicare Advantage is a popular alternative to traditional Medicare. Data recovery rates The privately run health plans have enrolled more than 17 million elderly and disabled people — about a third of those eligible for Medicare — at a cost to taxpayers of more than $150 billion a year. Database developer salary And while the plans generally enjoy strong support in Congress, there are critics.

“It’s unclear why the Obama Administration allowed CMS to overpromise and under-deliver so badly on collecting these overpayments,” Sen. Database backup and recovery Chuck Grassley, R-Iowa, told Kaiser Health News in an email response to the findings.

He said CMS “should account for why this process seems to be so broken and why it can’t seem to fix it, despite recommendations to do so. Yale b database The taxpayers depend on getting this process right.”

Yet outside of public view, federal officials have been losing a high-stakes battle to curb widespread billing errors by Medicare Advantage plans, according to the records obtained through a Freedom of Information Act lawsuit filed by the Center for Public Integrity.

The Center for Public Integrity first disclosed in 2014 that billions of tax dollars are wasted annually partly because some health plans appear to exaggerate how sick their patients are, a practice known in health care circles as “upcoding.”

Last August, the investigative journalism group reported that 35 of 37 health plans CMS has audited overcharged Medicare, often by overstating the severity of medical conditions such as diabetes and depression.

The newly released CMS records identify the companies chosen for the initial 2007 audits as a Florida Humana plan, a Washington state subsidiary of United Healthcare called PacifiCare, an Aetna plan in New Jersey and an Independence Blue Cross plan in the Philadelphia area.

Each of the five audits, which took more than two years to complete, unearthed significant — and costly — billing mistakes, though the plans disputed them.

For example, auditors couldn’t confirm that one-third of the diseases the health plans had been paid to treat actually existed, mostly because patient records lacked “sufficient documentation of a diagnosis.”

Overall, Medicare paid the wrong amount for nearly two-thirds of patients whose records were examined; all five plans were far more likely to charge too much than too little. Sybase database For 1 in 5 patients, the overcharges were $5,000 or more for the year, according to the audits. Database design None of the plans would discuss the findings.

As preliminary results of the audits started to roll in, CMS officials outlined steps to recover more than $128 million from the five plans at a confidential agency briefing in August 2010, according to a policy memo prepared for the meeting. Database 3 normal forms The records don’t indicate who attended.

That day, CMS set Humana’s payment error at $33.5 million, PacifiCare at $20.2 million, Aetna at $27.6 million, Independence Blue Cross at nearly $34 million and Lovelace at just under $13 million. Database for dummies Those estimates were based on extrapolation of a sample of cases examined at each plan.

But that process fizzled after two years of haggling with the plans and insurance industry representatives, who argued the audits were flawed and the results unreliable. A database is a collection of In August 2012, CMS gave in and notified the plans it would settle for a few cents on the dollar.

“Given this was a new process, the decision was made at the time to tie repayments to the actual claims reviewed as part of the 2007 pilot audit,” said CMS spokesman Aaron Albright. Library database “For subsequent audits, we said we intended to determine repayments by extrapolating the error rate of the sample of claims reviewed to all claims under the contract.” Albright said more of the audits are underway. Database node Allowing the insurers to dodge liability dealt a serious blow to the government’s efforts to crack down on billing abuses — a setback one taxpayer advocate called alarming.

“That’s a very bad way to operate the system.” said Patrick Burns, acting executive director and president of Taxpayers Against Fraud in Washington, on hearing of the outcome. Data recovery after format “Nobody is held accountable.”

Indeed, CMS kept the settlement terms under wraps until 2015, after an inquiry by Grassley. Database 2015 The senator had requested details about Medicare Advantage fraud controls in response to articles published by the Center for Public Integrity.

In a July 31, 2015, letter to Grassley, CMS Acting Administrator Andy Slavitt attached a table that showed the five plans repaid just under $3.4 million. Data recovery nyc The letter didn’t mention the earlier estimate that the government was due $128 million. Database weekly Grassley said it should not have taken the FOIA lawsuit to make that information available to the public.

The method, phased in starting in 2004, seemed simple enough: pay higher rates for sicker patients and less for people in good health using a formula called a risk score.

But CMS officials soon realized that risk scores rose much faster at some plans than others, a possible sign of upcoding, or other billing irregularities, records show. Data recovery utah These overcharges topped $4 billion in 2005, one CMS study found.

The special audits, called Risk Adjustment Data Validation, or RADV, were designed to identify, and hold accountable, health plans that couldn’t justify their fees with supporting medical evidence.

In the five 2007 pilot audits, two sets of auditors inspected medical records for a random sample of 201 patients at each plan. Data recovery deleted files If the medical chart didn’t properly document that a patient had the illnesses the plan had reported, Medicare wanted a refund. Database health check Auditors gave the plans the benefit of the doubt when auditors couldn’t agree, according to the CMS briefing paper.

Finally, CMS applied a standard technique used in fraud investigations in which the payment error rate is extrapolated across the entire health plan, which greatly multiplies the amount due. R studio data recovery software CMS said it was conservative in assessing the penalties and allowed the plans to appeal.

Appeals or no, the health plans recoiled at the prospect they could be on the hook for millions of dollars they hadn’t budgeted for and didn’t believe they owed. Data recovery iphone The actual 2007 overage for the 201 Humana patients, for example, was $477,235. Ease use data recovery Once extrapolated, it soared to $33.5 million.

Michael S. Free database software Adelberg, a former CMS official who is now an industry consultant in Washington, said that in retrospect the audit process was “probably rushed.”

Adelberg said the audits “raised strong industry concerns” on a variety of fronts, from whether CMS had the legal authority to conduct them to the soundness of their methods. Raid 0 data recovery software CMS stands by its audit techniques and has defended RADV as the only way it can assure plans bill honestly.

Yet agency records released through the FOIA case suggest CMS lacked the will to press ahead with extrapolated audits for Medicare Advantage plans given the fierce industry backlash — even though they do so in overpayment cases targeting other types of medical providers.

One confidential CMS presentation dated March 30, 2011, notes that officials had received more than 500 comments expressing “significant resistance” to the RADV audits.

CMS didn’t overcome those challenges. Mail database Instead, it agreed to settle the five initial audits for $3.4 million, just what it found in the patient files it reviewed — without the extrapolations. Hdata recovery master And the center did the same for 32 additional 2007 audits, which officials had predicted would refund up to $800 million to the federal treasury. In database In the end, CMS wound up with $10.3 million from the 32 plans.

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