(C) Daily Kos This story was originally published by Daily Kos and is unaltered. . . . . . . . . . . CMS to "claw back" billion$ from fraudulent Medicare Advantage plans. [1] ['This Content Is Not Subject To Review Daily Kos Staff Prior To Publication.', 'Backgroundurl Avatar_Large', 'Nickname', 'Joined', 'Created_At', 'Story Count', 'N_Stories', 'Comment Count', 'N_Comments', 'Popular Tags'] Date: 2023-02-04 FOR BACKGROUND see Advantage plans defrauded Medicare $11billion+ in 2022 alone and DK tag for diaries about or including MedicareAdvantage as a topic, also other tags in left margin. For years, federal regulators had voiced payment abuse concerns. but with no significant audit or financial deterrents to rein excesses in. Among the factors, risk-adjusted scores for raising payments for Advantage plans sicker members (e.g., chronically ill and disabled elders) which federal regulators found incentivizing plans to “game the system.” — the HHS Office of Inspector General (OIG) has flagged the use of health risk assessments used by plans to collect member information for boosting risk scores. A previous OIG report said that by CMS’ own estimates, Medicare made $50 billion in overpayments from 2013 through 2017 [based on] “from plan-submitted diagnoses that were not supported by beneficiaries’ medical records.” Health-med insurance industry groups such as AHIP (formerly America's Health Insurance Plans) and the Better Medicare Alliance have dismissed newly released data as “misleading” and “more than a decade old” as if time has made early fraud irrelevant. But it took a three-year Freedom of Information lawsuit alone by KHN to make key data public. This while Medicare Advantage plans have faced mounting criticism from government watchdogs and in Congress, the industry has tried to rally seniors to its side while disputing audit findings and research that asserts the program costs taxpayers more than it should . As the correction process begins, a Medicare Advantage milestone is expected this year: more seniors enrolled in MA plans than in traditional fee-for-service Medicare. FROM CMS EMAIL Monday JANUARY 30, 2023 Today, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), finalized the policies for the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program, which is CMS’s primary audit and oversight tool of MA program payments. Under this program, CMS identifies improper risk adjustment payments made to Medicare Advantage Organizations (MAOs) in instances where medical diagnoses submitted for payment were not supported in the beneficiary’s medical record. The commonsense policies finalized in the RADV final rule (CMS-4185-F) will help CMS ensure that people with Medicare are able to access the benefits and services they need, including in Medicare Advantage, while responsibly protecting the fiscal sustainability of Medicare and aligning CMS’s oversight of the Traditional Medicare and MA programs. As required by law, CMS’ payments to MAOs are adjusted based on the health status of enrollees, as determined through medical diagnoses reported by MAOs. Studies and audits done separately by CMS and the HHS Office of Inspector General (OIG) have shown that Medicare Advantage enrollees’ medical records do not always support the diagnoses reported by MAOs, which leads to billions of dollars in overpayments to plans and increased costs to the Medicare program as well as taxpayers. Despite this, no risk adjustment overpayments have been collected from MAOs since Payment Year (PY) 2007. “Protecting Medicare is one of my highest responsibilities as Secretary, and this commonsense rule is a critical accountability measure that strengthens the Medicare Advantage program. CMS has a responsibility to recover overpayments across all of its programs, and improper payments made to Medicare Advantage plans are no exception,” said HHS Secretary Xavier Becerra. “For years, federal watchdogs and outside experts have identified the Medicare Advantage program as one of the top management and performance challenges facing HHS, and today we are taking long overdue steps to conduct audits and recoup funds. These steps will make Medicare and the Medicare Advantage program stronger.” “CMS is committed to protecting people with Medicare and being a responsible steward of taxpayer dollars,” said CMS Administrator Chiquita Brooks-LaSure. “By establishing our approach to RADV audits through this regulation, we are protecting access to Medicare both now and for future generations. We have considered significant stakeholder feedback and developed a balanced approach to ensure appropriate oversight of the Medicare Advantage program that aligns with our oversight of Traditional Medicare.” The RADV final rule reflects CMS’s consideration of extensive public comments and robust stakeholder engagement after the release of the 2018 Notice of Proposed Rulemaking. The finalized policies will also allow CMS to continue to focus its audits on those MAOs identified as being at the highest risk for improper payments. The RADV final rule can be accessed at the Federal Register here: https://www.federalregister.gov/public-inspection/2023-01942/medicare-and-medicaid-programs-policy-and-technical-changes-to-the-medicare-advantage-medicare View the fact sheet on the final rule here: https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-risk-adjustment-data-validation-final-rule-cms-4185-f2-fact-sheet. 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