Federal officials are planning a wide range of audits into billing and government spending on managed health care in the new fiscal year, ranging from private Medicare Advantage groups that treat millions of elderly to health plans rapidly expanding under the Affordable Care Act.
The Health and Human Services Office of Inspector General, which investigates Medicare and Medicaid waste, fraud and abuse, said it would conduct “various reviews” of Medicare Advantage billing practices with an eye toward curbing overcharges. Results are due next year.
The Inspector General also announced from five to ten new audits into Obamacare, ranging from the accuracy of “financial assistance” payments for new enrollees to controls to prevent fraudulent sign ups.
The Inspector General’s office did not say if individual Medicare Advantage plans would be audited, but indicated it would focus on concerns that some health plans exaggerate how their sick patients are to overcharge the government — the subject of a recent Center investigation.
“Prior OIG reviews have shown that medical record documentation does not always support the diagnoses” (used to bill Medicare),” the Inspector General said. “Efforts for FY 2015 and beyond may include additional work examining the soundness of rates and risk and payment adjustments,” the Inspector General said.
The audits are among dozens of new projects spelled out in the Inspector General’s 2015 “work plan” posted on the agency’s website late last week. While much of the plan focuses on managed care, the Inspector General also plans to audit spending on other programs, such as one paying billions of dollars to doctors and hospitals that purchased electronic health records.
The OIG work plan serves as a blueprint for enforcement actions during the upcoming year and calls attention to medical initiatives officials believe are vulnerable to fraud and abuse. The FY2015 fiscal year began October 1 and runs through Sept. 30, 2015.
Many of the audits are described only briefly in the work plan or are couched in bureaucratic language that makes it difficult to judge their potential impact.
The Inspector General is continuing to pursue allegations of billing fraud and abuse by doctors, hospitals and medical suppliers, such as ambulance companies and sellers of diagnostic gear. But it appears to be placing more emphasis on managed care than in the past.
The agency also said it planned to look into what it described as “emerging vulnerabilities” in a wide range of Obamacare programs; the work plan noted that Medicaid, the health plan for low income people, is growing explosively under the health reform law.
“Protecting an expanding Medicaid program from fraud, waste, and abuse takes on a heightened urgency as the program continues to grow in spending and in the number of people it serves,” the Inspector General wrote.
Keeping tabs on managed care spending presents a particular challenge for fraud fighters, who are accustomed to bringing cases against companies that bill for services never rendered.