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Medicare Advantage Plans' Fraud Oversight Weak, Says OIG

John Commins, for HealthLeaders Media, February 27, 2012

One organization accounted for 78% of the total 1.4 million incidents of potential Part C and Part D fraud and abuse. Excluding the 95% of all reported incidents that were linked to three Medicare Advantage organizations, 134 organizations identified a total of 73,499 potential fraud and abuse incidents in 2009. Of those, 83% were linked to Part C. Those 134 organizations covered 9.9 million beneficiaries in 2009.

Size apparently was not a factor in organizations' ability to monitor waste and fraud. "For example, an organization with more than 250,000 enrollees identified 37 potential Part C fraud and abuse incidents and 8 potential Part D incidents. Another organization, which had fewer than 5,000 enrollees, identified 7,787 potential Part C fraud and abuse incidents and 154 potential Part D incidents," OIG said.

The 134 Medicare Advantage organizations reported 32 different types of Part C incidents in 2009. The most common related Part C was improper coding of services. The organizations identified 25 different types of potential fraud and abuse related to Part D, and inappropriate prescription dispensing was the most common.


John Commins is a senior editor with HealthLeaders Media.

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