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Biden administration targets Medicare Advantage fraud

On Behalf of | Apr 3, 2023 | Medicare / Medicaid Fraud

Medicare watchdogs have been vocal about the insurance companies stealing billions from taxpayers through the emergent Medicare Advantage plan, which is the choice of half of all Medicare beneficiaries. These private plans offered by insurers have lower premiums than regular Medicare and provide additional benefits like dental. It is considered one of the most profitable plans in the industry thanks to its billing of Medicare programs. However, there are claims that insurance companies are submitting fraudulent bills claiming that customers are sicker than they are to inflate billing.

$4.7 billion in taxpayer savings

Enacted in January, the new rule better enables the government to audit plans and recover an overpayment. Advocates say the new regulations are the strongest action in over ten years. The Biden administration says it will address this problem with a series of new rules to hold the insurers more accountable, with three of the five largest insurers accused of fraud by the Justice Department. In rolling out the new oversight, the administration claims it will collect up to $4.7 billion or more in the next decade.

Health insurers fight back

Carriers have lobbied heavily recently, even paying for a Superbowl Ad. The industry claims it is doing risk adjustment and will likely fight the new rules in court. Well-funded and with much sway in both Washington and the rest of the country, insurers claim they are ready to take on the federal government.

How it works

First proposed by the Trump Administration in 2018, regulators scrutinize a subset of patient medical records and compare them to all medical claims in plans since 2018. If the data on billing codes is out of sync with the general population’s, the federal government could increase the amount of repayments. According to the New York Times, insurers overcharged the government by nearly a half-billion dollars in 2018. The new rule could go further by making the regulation retroactive, perhaps as far back as 2011, when the federal audits began.

Audits will not be enough

Federal regulators will still rely on help from whistleblowers to identify troubling billing trends and overbilling. Considering the amount of money at stake and the complexity of the issues surrounding Medicare, it is often wise to work with an attorney who represents health industry whistleblowers. These legal professionals can provide helpful guidance and protect the client’s interests, livelihood and rights.