A government watchdog has identified major concerns relating to health insurers exaggerating how sick their Medicare patients were, resulting in nearly $7 billion in improper payments, according to a report released on Dec. 12.
The payments were made after insurers added diagnoses to patients’ files that weren’t supported by their medical records.
Inspectors found that Medicare Advantage insurers had added diagnoses for diabetes, heart disease, and other conditions in 99.3 percent of chart reviews of patient information, even though they didn’t appear in records from doctors, hospitals, or other medical providers. Insurers deleted incorrect diagnoses less than 1 percent of the time, they found.
“Although limited to a small number of beneficiaries, almost half of MAOs reviewed had payments from unlinked chart reviews where there was not a single record of a service being provided to the beneficiary in all of 2016,” the summary continued.
The additional diagnoses boosted government payments to insurers by an estimated $6.9 billion, while the deleted information trimmed payouts by nearly $200 million, producing a net benefit of $6.7 billion for the companies.
“We could not see any services with the diagnosis and that raised a number of concerns,” Linda Ragone, a regional inspector general in Philadelphia and co-author of the report, told Reuters. “There is a vulnerability here that needs to be addressed.”
The report highlighted a group of 4,616 Medicare Advantage enrollees for whom insurers added a diagnosis that resulted in a higher payment, even though there was no record of the person receiving any medical services during the year under review. The report didn’t identify any specific insurers by name.
The OIG also listed recommendations in their report including providing “oversight of MAOs that had payments resulting from unlinked chart reviews for beneficiaries who had no service records.” It also suggested conducting reviews that validated the diagnoses reported on chart reviews and to “reassess the risks and benefits of allowing unlinked chart reviews to be used as sources of diagnoses for risk adjustment.”
The U.S. Centers for Medicare and Medicaid Services (CMS) should be doing more to prevent insurers from exploiting this vulnerability, the OIG stated.
CMS didn’t immediately respond to a request for comment from The Epoch Times, but it told Reuters that it is “committed to ensuring that Medicare Advantage plans submit accurate information to CMS so that payments to plans are appropriate.”
In a Nov. 1 letter to the OIG cited in the report, CMS challenged the $6.7 billion estimate of payments linked to chart reviews as too high. The agency agreed with the report’s recommendations for increased oversight and audits.
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