{"id":260691,"date":"2025-05-28T00:05:38","date_gmt":"2025-05-28T00:05:38","guid":{"rendered":"https:\/\/peraltafinancing.com\/business\/finance\/medicare-advantage-plans-come-under-fire-from-doge\/"},"modified":"2025-05-28T00:05:38","modified_gmt":"2025-05-28T00:05:38","slug":"medicare-advantage-plans-come-under-fire-from-doge","status":"publish","type":"post","link":"https:\/\/fivemor.com\/?p=260691","title":{"rendered":"Medicare Advantage plans come under fire from DOGE"},"content":{"rendered":"


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Health insurers are on alert after the Centers for Medicare & Medicaid Services announced May 22 that it is immediately expanding audits of all Medicare Advantage (MA) contracts and adding resources to complete overdue 2018-2024 audits.<\/p>\n

Many older Americans flock to Medicare Advantage programs because of cheaper premiums and, in some states, more over-the-counter (OTC) benefits like vision, dental, prescriptions and even food. <\/p>\n

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However, repeated studies have shown that MA coverage costs the federal government more than traditional Medicare, despite significant concerns that private insurers may deny justifiable care.<\/p>\n

Of the 67.3 million Americans enrolled in Medicare, approximately 35 million are in Medicare Advantage plans. Total federal Medicare spending is approximately $1 trillion annually but an estimated $84 billion goes to MA plans. <\/p>\n

Because of the way Medicare Advantage payments are structured, payouts are often adjusted upwards, in part for the additional OTC benefits not found in traditional Medicare.\u00a0<\/p>\n

Some MA plans may use more aggressive diagnosis findings than what the patient actually has, a practice known as upcoding that raises reimbursements.<\/p>\n

CMS Medicare Advantage audits seek to uncover fraud<\/h2>\n

Medicare Advantage plans receive risk-adjusted payments based on the diagnoses they submit for enrollees, meaning higher payments for patients with more serious or chronic conditions.\u00a0<\/p>\n

To verify the accuracy of these claims, CMS conducts Risk Adjustment Data Validation (RADV) audits to confirm that medical records support diagnoses used for payment.<\/p>\n

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Currently, CMS is several years behind in completing these audits.\u00a0<\/p>\n

The last significant recovery of MA overpayments occurred following the audit of payment year (PY) 2007, despite federal estimates suggesting MA plans may overbill the government by approximately $17 billion annually.\u00a0<\/p>\n

The Medicare Payment Advisory Commission (MedPAC) estimates this figure could be as high as $43 billion per year. CMS\u2019s completed audits for PYs 2011\u20132013 found between 5 and 8 percent in overpayments.<\/p>\n

To address this backlog, the Trump Administration has introduced a plan to complete all remaining RADV audits by early 2026. Key elements of the plan include:<\/p>\n