McCaskill: Medicare Advantage billing fraud ‘must be investigated’

Introduction

U.S. Senator Claire McCaskill wants federal officials to step up oversight of privately-run Medicare Advantage health plans treating the elderly, citing allegations by whistleblowers that some health plans are overcharging the government for their services.

It is the second recent call by a U.S. Senator for enhanced scrutiny of billing practices in the popular private health plans, which treat more than 16 million seniors.

Last week, Senate Judiciary Committee Chairman Charles E. Grassley asked Attorney General Loretta Lynch to tighten scrutiny of Medicare Advantage health plans suspected of overcharging the government, saying billions of tax dollars are at risk as the senior care program grows.

Both McCaskill, a Missouri Democrat, and Grassley, an Iowa Republican, cited concerns over the accuracy of a billing tool called a “risk score,” which is intended to pay Medicare Advantage insurers higher rates for taking sicker people and less for those with few medical needs.

But federal officials have struggled for years to track overspending tied to inflated risk scores that prompt overbilling. A 2009 agency study found that some plans had exaggerated how sick patients were to boost their payments, for instance. CMS also has acknowledged that faulty risk scores remain a costly problem, as the Center for Public Integrity first reported last year.

In a May 26 letter to CMS administrator Andrew Slavitt, McCaskill asked for a briefing on steps the government is taking to combat risk scoring fraud and abuse.

“With fraudulently inflated risk scores potentially costing taxpayers billions of dollars every year and resulting in less money in the Medicare Trust Funds for our seniors, this is an issue that must be investigated further,” McCaskill wrote.

‘Time and again’

“Gaming the Medicare Advantage system is a threat to taxpayers, but also to Medicare beneficiaries–and we should be doing everything possible to aggressively pursue anyone engaged in wrongdoing,” said McCaskill, the top-ranking Democrat on the Senate Special Committee on Aging.

McCaskill cited the Center for Public Integrity and NPR reports that uncovered federal whistleblower lawsuits alleging that some Medicare Advantage plans have taken steps to inflate risk scores to overcharge the government.

“Time and again we’ve seen whistleblowers allege outright fraud when it comes to risk scores, and to me that’s a sign there’s simply not enough oversight taking place.”

Medicare Advantage plans have gained popularity as an alternative to the government-run Medicare program in recent years, and the plans now cover about one in three people eligible for Medicare at an annual cost topping $150 billion.

But McCaskill noted that in 2014, the Government Accountability Office reported that more than $12 billion in “improper” payments to Medicare Advantage plans tied to faulty risk scores.