Grassley Continues Oversight of Medicare Advantage Payments

Sen. Chuck Grassley continues his oversight of whether the taxpayers are overpaying insurers in Medicare Advantage, seeking updates and answers from the Centers for Medicare and Medicaid Services (CMS) on what the agency is doing to prevent insurance company risk score gaming to get higher payments. 

“By all accounts, risk score gaming is not going to go away,” Grassley wrote to CMS Administrator Seema Verma.  “Therefore, CMS must aggressively use the tools at its disposal to ensure that it is efficiently identifying fraud and subsequently implementing timely and fair remedies. The use of these tools is all the more important as Medicare Advantage adds more patients and billions of dollars of taxpayer money is at stake.”

In response to a prior Grassley inquiry, CMS noted prior audits of Medicare Advantage organizations and the recovery of taxpayer money.  However, CMS failed to note an initial overpayment assessment of $128 million for five health plans in 2007, compared to the $3.4 million actually recovered by the government in 2012.  The overpayment assessment came to light only through investigative reporting by the Center for Public Integrity.

“The difference in the assessment and the actual recovery is striking and demands an explanation,” Grassley wrote.  “Further, in light of the $70 billion in risk score overpayments between 2008-2013 reported by the Center for Public Integrity, CMS’s 2007 overpayment estimate of $128 million appears low and could very well be just the tip of the iceberg.”

Grassley asked a series of question on what CMS is doing to ensure that insurance companies are not gaming Medicare, why CMS under the Obama Administration didn’t disclose the $128 million over-payment assessment, why the prior administration recovered $3.4 million instead of $128 million, how many Medicare Advantage audits have been performed and how many are ongoing, and whether CMS’ position remains that it obligates $30 million per year auditing Medicare Advantage.

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