A KHN investigation found when some Medicare Advantage plans got a rare federal audit, they couldn't produce billing records for care they said they'd provided. Some blamed fire, flood — or doctors.
, auditors uncovered millions of dollars in improper payments — citing overcharges of more than $1,000 per patient a year on average — by nearly two dozen health plans.
Medicare reimburses Medicare Advantage plans using a complex formula called a risk score that computes higher rates for sicker patients and lower ones for healthier people. In many cases, auditors found that the medical credentials of the health care provider who made the diagnosis were unclear, the records provided were unacceptable, or the record lacked a signature as required. Other files bore the wrong patient's name or were missing altogether.
Other Medicare Advantage health plans argued they had no luck retrieving medical records from doctors who had moved, retired, died — and in some cases been arrested or lost their licenses for misconduct. The indictment accused him of creating an electronic medical record that fraudulently added billing codes for treatment of medical conditions patients didn't necessarily have, including vascular disease.
Dara Corrigan, a CMS deputy administrator, said that as a"general matter," its Medicare Advantage audits"are not designed to detect fraud, nor are they intended to identify all improper diagnosis submissions."The costs to taxpayers from improper payments have mushroomed over the past decade as
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