UnitedHealth Doctored Medicare Records, Overbilled U.S. By $1 Billion, Feds Claim | California Healthline

The complexities of billing Medicare in Medicare Advantage Programs is leading to fraudulent claims.

Advantage plans are paid by Medicare according to a risk sharing formula and payments can vary from year to year.

By Fred Schulte

In a 79-page lawsuit filed in Los Angeles, the Justice Department alleged that the insurer made patients appear sicker than they were in order to collect higher Medicare payments than it deserved. The government said it had “conservatively estimated” that the company “knowingly and improperly avoided repaying Medicare” for more than a billion dollars over the course of the decade-long sche

UnitedHealth Doctored Medicare Records, Overbilled U.S. By $1 Billion, Feds Claim | California Healthline

Medicare pays the health plans using a complex formula called a risk score, which is supposed to pay higher rates for sicker patients than for people in good health. But waste and overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity concluded that improper payments linked to jacked-up risk scores have cost taxpayers tens of billions of dollars.

Tuesday’s court filing argues that UnitedHealth repeatedly ignored findings from its own auditors that risk scores were often inflated — and warnings by officials from the Centers for Medicare & Medicaid Services (CMS) — that it was responsible for ensuring the billings it submitted were accurate.

All but two of 37 Medicare Advantage plans examined in a 2007 audit were overpaid — often by thousands of dollars per patient. Overall, just 60 percent of the medical conditions health plans were paid to cover could be verified. The 2007 audits are the only ones that have been made public.

Audits in these cases are difficult to trace. One factor may be due to inaccurate coding and/or incomplete medical records from providers notes in either a chart or in an EHR.   This may be due to time pressures  and inadequate time allotment for providers to complete their CPT and ICD coding.

While the feds are focused on the insurance companies, part of the blame may rest on providers themselves...insulated now by another level of bureaucracy.  In an effort to reduce CMS cost, CMS has shifted the burden to Advantage plans.  The blame game comes into operation in this case.

The current complexity of billing is such that it encourages omissions and faulty record keeping. CMS audits numbers, codes for CPT and ICD, in a digital manner, not an analog manner.

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This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.