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Medicare Advantage Plans' Fraud Oversight Weak, Says OIG

John Commins, for HealthLeaders Media, February 27, 2012

Federal inspectors are calling for tighter oversight of waste, fraud, and abuse in Medicare Advantage after a first-ever system-wide audit of the program found wide disparities in vigilance and reporting among the privately run plans.

"Our findings indicate that Medicare Advantage organizations lack a common understanding of key fraud and abuse program terms and raise questions about whether all Medicare Advantage organizations are implementing their programs to detect and address potential fraud and abuse effectively," the report said.

The audit  from the Department of Health and Human Services Office of Inspector General reviewed 2009 data from 170 of the 188 Medicare Advantage organizations that represented 4,547 plans nationwide and accounted for 94% of the 10.9 million Medicare Advantage beneficiaries in 2009.

The audit did not name the Medicare Advantage organizations.

Three Medicare Advantage organizations identified 95% of the 1.4 million incidents related to their Part C health benefits and Part D drug benefits that year, while 19% of the organizations reported no potential fraud and abuse. Overall, Medicare Advantage plans sent only 2,656 referrals of potential fraud and abuse for further investigation.

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