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.

© 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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