On Top of RADV and Other Enforcement Tools, MA Insurers Should Watch False Claims Act Space

As the federal government seeks ways to accelerate recovery of overpayments made to Medicare Advantage organizations, the False Claims Act (FCA) remains a critical tool in combating fraud, waste and abuse and enforcing program requirements. Of the more than $2.2 billion in settlements and judgments reported by the Dept. of Justice (DOJ) for the fiscal year ending Sept. 30, 2022, more than $1.7 billion related to matters involving the health care industry, including drug and medical device manufacturers, durable medical equipment, home health vendors and managed care providers. While much of the DOJ’s recent recovery efforts have centered on fraud in pandemic relief programs, the government remains focused on allegations involving MA insurers submitting inaccurate diagnosis information for the purposes of receiving higher risk-adjusted reimbursement.

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• Radar on Medicare Advantage