Most of $9.2 Billion in Questionable Medicare Payments Went to 20 Insurers, Investigators Say
An investigation by the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services hints at underhanded practices that garnered private health plans millions of dollars in Medicare payments they should not have received. The finding suggests that companies under the Medicare Advantage (MA) umbrella may have manipulated procedures for documenting patients' medical diagnoses. Such documentation dictates how much insurers are paid, with more and graver conditions generally equating to more Medicare dollars. In particular, the OIG report raised concerns over the use of chart reviews, which scrutinize patient records for diagnoses not specially flagged by physicians, and health risk assessments, which typically are performed by vendors in patients' homes. While both approaches are permitted, many diagnoses were not supported by documented care. The suspect diagnoses unfairly earned MA companies more than $9 billion in 2017 linked to enrollment and documentation the year before. A group of 20 companies accounted for more than one-half of the total, with the other 46% spread among 142 other MA insurers.
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