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Watchdog Questions $6.7 Billion in Medicare Payments

Michael Rainey

Health insurance companies in the Medicare Advantage program have received billions in extra payments after making adjustments to their patient charts – changes that the Department of Health and Human Services inspector general says “raise concerns.”

According to an IG report released this week, insurers have used a chart review process to add medical conditions such as diabetes and cancer to patient records, earning higher payments from Medicare to compensate for the risk of caring for sicker patients. But in many cases, the charts did not indicate that a medical service related to the added illness had been provided, raising questions about the legitimacy of the adjustments.

Illnesses added to charts but unrelated to any specific medical service resulted in $6.7 billion in risk-adjusted payments in 2017, the IG said. While the watchdog did not conclude that the payments were necessarily illicit, it did recommend that the government provide better oversight of the chart review and risk adjustment process.

The increasingly popular Medicare Advantage program covered 21 million people in 2018 and accounted for $210 billion of Medicare’s $711 billion in spending.

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