OIG report finds insurers collected billions in questionable MA payments

Oct 24, 2024 - 03:30 PM
Eyeglasses sit on a folded newspaper on top of a laptop keyboard.

A report released Oct. 24 by the Office of Inspector General found that insurers received an estimated $7.5 billion in Medicare Advantage risk-adjustments for 2023 through health risk assessments and related medical record reviews. OIG said the lack of any other follow-up visits, procedures, tests or supplies for these diagnoses in the MA encounter data raises concerns that either the diagnoses are inaccurate, thus the payments are improper, or MA enrollees did not receive needed care for serious conditions reported only on HRAs or HRA-linked chart reviews. In-home HRAs and HRA-linked chart reviews generated nearly two-thirds of the estimated $7.5 billion, the report said. According to OIG, UnitedHealth Group and Humana accounted for over $5.4B of the estimated $7.5B.

Related News Articles

Headline
AHA shares concerns, recommendations with CMS on WISeR model
The AHA Oct. 23 recommended changes to the Centers for Medicare & Medicaid Services’ Wasteful and Inappropriate Services Reduction model to address…
Headline
OIG says MA, Medicaid managed care plans have limited, inaccurate behavioral health provider networks 
A report by the Department of Health and Human Services Office of the Inspector General found that many Medicare Advantage and Medicaid managed care plans…
Headline
Medicare open enrollment for 2026 begins
Medicare open enrollment for 2026 began Oct. 15 and runs through Dec. 7. During the annual enrollment period, Medicare-eligible individuals can check their…
Headline
AHA encourages MedPAC to refine analysis of MA enrollment impacts on patients, providers
The AHA Oct. 3 responded to the Medicare Payment Advisory Commission’s recent analysis on the financial impacts of Medicare Advantage enrollment growth on…
Headline
CMS finalizes Medicare Part C Utilization Management Annual Data Submission requirements 
The Centers for Medicare & Medicaid Services Sept. 30 issued a memo, through the Health Plan Management system, finalizing the Medicare Advantage…
Headline
AHA provides recommendations to HHS, CMS for insurers to adhere to prior authorization pledge 
The AHA Sept. 29 sent recommendations to the Department of Health and Human Services and the Centers for Medicare & Medicaid Services to help ensure…