McKnight's September 16, 2024
In the realm of Medicare, Medicare Advantage (MA), and Commercial Insurance claims, requests for records and claim reviews are commonplace. Insurers generally follow similar processes for these reviews, which can include both prepayment and post-payment audits as outlined by CMS for Medicare programs. The primary objective of these reviews is to minimize improper payments. According to CMS’s FY 2023 Improper Payment Fact Sheet, the estimated improper payment rate for Medicare Fee-for-Service (FFS) was 7.38%, or $31.2 billion, while for Medicare Part C (Medicare Advantage), it was 6.01%, or $16.6 billion1. Although Commercial Insurers are not subject to the same reporting standards, it is reasonable to assume their error rates are comparable. CMS is mandated to audit and report on these...
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