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Medicare Advantage Plans' Fraud Oversight Weak, Says OIG

John Commins, for HealthLeaders Media, February 27, 2012

"Differences in the way organizations defined and detected potential fraud and abuse may account for some of the variability in the number of incidents they identified," the audit stated. "While CMS requires MA organizations to initiate inquiries and corrective actions where appropriate, not all MA organizations took such steps in response to incidents they identified."

Auditors recommended that the Centers for Medicare and Medicaid Services take action to ensure that Medicare Advantage organizations effectively monitor fraud and abuse.

Those steps would include:

  • Determining why some plans reported especially high or low cases of suspected fraud and abuse;
  • Developing guidelines for plans to define potential Part C and Part D fraud and abuse;
  • Requiring plans to give CMS aggregate data related to Part C and Part D antifraud, waste and abuse activities;
  • Requiring Medicare Advantage plans to refer potential fraud and abuse to CMS or other investigators.   

In a written response to the audit, CMS Acting Administrator Marilyn Tavenner agreed with most of the findings and noted that CMS has already begun enhanced auditing of Medicare Advantage organizations to detect fraud and abuse. Tavenner said, however, that CMS does not have the statutory authority to require mandatory self-reporting of fraud and abuse by Medicare Advantage organizations.

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