The government recently announced the findings of a series of audits conducted on Medicare billing from 2011 through 2013. The audits allegedly find that the government overpaid various organizations more than $12 million in claims during this relatively short time period.
The audits focused on payouts through the Medicare Advantage program. At the time of the findings, nearly a decade ago, the government announced a plan to recoup at least $650 million in these overpayments by extrapolating the payment error rates across the total membership.
The US Center for Medicare and Medicaid Services (CMS) was set to announce the extrapolation rule in November but pushed that back to February.
Why are we just finding out about this?
Although the information is more than a decade old, we are only now finding out about the results due to a recent lawsuit filed by Kaiser Health News. The lawsuit used the Freedom of Information act to demand the government release this information.
Why does this matter?
Again, it is important to point out that the government conducted these audits over a decade ago. Since that time, the use of the Medicare Advantage program has more than doubled. The amount of alleged overpayments that occurred during that time could be astronomical.
Although this issue focuses specifically on healthcare insurance companies, healthcare organizations and practices should take note of the issue as the CMS has announced a focus on higher claims for sicker patients as a direct result of these audits. Small practice or massive insurance company aside, if the medical records do not support these claims, the government will likely allege an overpayment and demand a return of the funds.
Attorney John Rivas is responsible for this communication