Medicare officials made a clear statement four years ago about how best to audit the country’s Medicare Advantage insurers: Failing to take back all overpayments “would be contrary to the public interest.”
But based on a final regulation published Monday, Medicare is going against that public interest by giving a free pass to Medicare Advantage plans for any erroneous codes they submitted between 2011 and 2017. The amount of taxpayer money that insurers will get to keep because of that decision: $2 billion.
“They gave the insurance companies a break,” said Melissa James, a senior health care consultant at Wolters Kluwer. James used to work at UnitedHealth Group and Aetna, where she internally audited the Medicare Advantage plans’ risk adjustment, chart review, and compliance. “There’s a bunch of money that is being left on the table by [the Centers for Medicare and Medicaid Services] by only doing the extrapolation from 2018 and beyond,” she said.
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