News Briefs: OIG Chief Says Agents Are ‘Struggling to Keep Up’ With Medicare, Medicaid Fraud

Testifying before the U.S. House Committee on Energy and Commerce, HHS Inspector General Christi Grimm identified Medicare Advantage risk adjustment and durable medical equipment as two areas at risk for fraud and improper payments. The current MA payment structure, which adjusts payments based on the relative health of beneficiaries, “creates an incentive for managed care plans to make patients appear sicker simply to claim payments to which they are not entitled,” she told representatives during the April 16 hearing. She noted that OIG identified MA overpayments across 33 audits totaling more than $500 million, an amount that “is likely just the tip of an iceberg.” She said these issues raise questions about the accuracy of the data and whether patients are receiving needed treatment. In addition, OIG’s work looking at Medicaid managed care demonstrates that “states need better, more useful data that would ensure states are not paying for deceased enrollees or paying for an enrollee who has moved to another state,” she said. OIG is “struggling to keep up” with the pace of the growing health care industry and is “declining 300 to 400 viable fraud cases per year because we don’t have the agents to work them,” she added.

© 2024 MMIT
Lauren Flynn Kelly

Lauren Flynn Kelly Managing Editor, Radar on Medicare Advantage

Lauren has been covering health business issues since the early 2000s and specializes in in-depth reporting on Medicare Advantage, managed Medicaid and Medicare Part D. She also possesses a deep understanding of the complex world of pharmacy benefit management, having written AIS Health’s Radar on Drug Benefits from 2004 to 2005 and again from 2011 to 2016. In addition to her role as managing editor of Radar on Medicare Advantage, she oversees AIS Health’s publications and manages the health editorial staff. She graduated from Vassar College with a B.A. in English.

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