Becker's Healthcare February 2, 2023
More scrutiny is expected for providers who serve patients covered by Medicare Advantage.
On Jan. 30, CMS said it will implement stricter auditing practices around MA plans, a move that could leave commercial payers collectively on the hook for up to $4.7 billion in repayments to the federal government over the next decade. The final rule will only apply to contracts dated from payment year 2018 and up.
Nearly every major insurance company has been accused of or settled allegations of MA fraud, which the industry disputes. Payers are accused of exploiting the program through “upcoding” schemes that make patients appear sicker on medical records than they actually are — thereby leading to higher payments from CMS. Some diagnoses...
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