Government Overpayments to Medicare Advantage Plans are a major problem.

CMS pays Medicare Advantage Plans per member based on a risk score. The more chronic conditions the person has, the larger the payments CMS makes to the Medicare Advantage Plan.

Medicare Advantage Plans may be overexaggerating how sick their members are in order to increase their payments from CMS.

The Department of Justice is currently suing Cigna and Elevance (Anthem) for such over exaggerations.

However there is a deeper problem... CMS itself has performed its own audits, but has not done so in 10 years. CMS identified $650M in overpayments and did nothing about them.

When the Kaiser Family Foundation (KFF) requested information on the audits, CMS refused. KFF had to sue CMS to obtain the audit information and it took 3 years for KFF to win the case.

Perhaps it is incompetence on the part of CMS or perhaps CMS does not want to reveal the audits or do anything about them due to political pressure.

Sources:
https://www.npr.org/sections/healths....

https://www.commonwealthfund.org/blog...

https://www.reuters.com/legal/ussues...

https://www.fiercehealthcare.com/paye...

https://www.fiercehealthcare.com/prov...

https://www.opensecrets.org/elections...

AHealthcareZ is 300+ Healthcare Finance Educational Videos.

BOOK: Check out Dr. Bricker’s Book 16 Lessons in the Business of Healing here: https://www.ahealthcarez.com/healthca...

AHealthcareZ Viewers Include: Employee Benefits Professionals, HR, CFOs, Insurance Brokers, Benefits Consultants, Doctors and Nurses in Leadership Roles, Hospital and Health System Administrators, Health Insurance Carrier and PBM Professionals, Pharma and Med Device Professionals, Academic Professors and Students in Healthcare Administration and Public Health.

90,000+ Views Per Month Across All Platforms.

Visit AHealthcareZ.com to Subscribe to the Healthcare Finance Video Newsletter.