Medicare Advantage insurers lack a “common understanding” about federal anti-fraud requirements and that may limit their ability to detect and mitigate the problem, according to a broad review of those entities by HHS' inspector general's office.
Advantage plans vary on fraud detection: study
The agency study of insurers covering 94% of Medicare beneficiaries enrolled in Medicare Advantage plans in 2009 found wide variation in the rate of potential fraud incidents flagged by plans and in their rate of reporting those incidents for further investigation. For instance, only three of 170 such insurers identified 95% of the 1.4 million incidents of suspected fraud or abuse.
“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,” according to the report.
The CMS requires those insurers to initiate “inquiries and corrective actions” in some cases and not all of them took such actions in the suspected fraud cases they identified, the inspector general's office found.
The CMS agreed with several of the inspector general's recommendations to address the problem and plans to provide updated instructions to them on implementing a program “to detect, correct, identify, and prevent fraud, waste, and abuse.”
However, the agency rejected other recommendations, such as performing a program-wide review of all such insurance plans to determine why such wide variation occurred in their reports of suspected fraud and abuse.
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