Kaiser Health News is suing the U.S. Centers for Medicare & Medicaid Services to launch dozens of audits that the company says reveal a whole bunch of tens of millions of in overcharges by Medicare Advantage well being plans.
The suit, filed late Thursday in U.S. District Court in San Francisco beneath the Freedom of Information Act, seeks copies of 90 authorities audits of Medicare Advantage well being plans carried out for 2011, 2012 and 2013 however by no means made public. CMS officers have mentioned they count on to gather $650 million in overpayments from the audits. Although the company has disclosed the names of the well being plans beneath scrutiny, it has not launched some other particulars.
“This action is about accountability for hundreds of millions of public dollars misspent,” mentioned Elisabeth Rosenthal, KHN’s editor-in-chief. “The public deserves details about the overpayments, since many of these private companies are presumably still providing services to patients and we need to make sure it can’t happen again.”
Medicare Advantage, largely run by personal insurance coverage corporations, has enrolled greater than 22 million seniors and folks with disabilities, greater than 1 in three individuals on Medicare.
On July three, KHN reporters filed a FOIA requesting copies of the CMS audits, that are referred to as Risk Adjustment Data Validation, or RADV, and embody the audit spreadsheets, cost error calculations and different data. CMS has but to answer that request, based on the go well with.
“By this FOIA action, KHN seeks to shine a public light on CMS’s activities on behalf of millions of Americans and their families,” the go well with states. The go well with asks the court docket to seek out that CMS violated the FOIA regulation and order the company to “immediately disclose the requested records.”
While Medicare publicly discloses audits of different medical companies, Medicare Advantage insurers “are being treated differently,” based on the go well with. “These audits are improperly being withheld by CMS, even though CMS estimates that these audits have identified some $650 million in improper charges,” the go well with alleges.
While proving fashionable with seniors, the Medicare Advantage trade has lengthy confronted criticism that it overcharges the federal government by billions of yearly.
Medicare pays the well being plans greater charges for sicker sufferers and fewer for these in good well being. However, the RADV audits have proven that well being plans usually can not doc whether or not many sufferers really had the medical circumstances the federal government paid them to deal with, producing overpayments. The secretive RADV audits are the first means for CMS to carry the trade accountable and claw again overcharges for the U.S. Treasury.
This month, U.S. Sen. Sherrod Brown, an Ohio Democrat, and 5 different senators despatched a letter to CMS Administrator Seema Verma asking her to research Medicare Advantage overbilling. “In many cases, CMS has known for years about the tendency for some MA plans to overbill the government yet, despite this, CMS has taken little to no action to course correct. It is critical that CMS act immediately to recoup these overpayments and prevent future overbilling by MA plans,” Brown wrote.
The insurance coverage trade is combating a proposal by CMS to develop the affect of RADV by extrapolating error charges present in a random pattern of sufferers to the plan’s full membership — a method anticipated to set off many multimillion-dollar penalties.
America’s Health Insurance Plans, the trade’s commerce affiliation, mentioned in an Aug. 28 statement that the CMS proposals “violate numerous statutory requirements and are fundamentally unfair and ill-conceived.”
Stepping up RADV penalties “could lead to higher costs, reduced benefits, and fewer MA plan options for seniors,” the group argued.
The FOIA lawsuit is the second by a media group to compel CMS to reveal RADV audit findings. In 2014, the Center for Public Integrity sued CMS and received a court docket order forcing the discharge of RADV audits for the primary time. The audits showed that 35 of 37 plans had been overpaid, in some instances by as a lot as $10,000 per affected person in a 12 months.