OIG will increase audit activities for Medicare Advantage plans in 2015

November 7, 2014

Audits of Medicare Advantage (MA) plans and healthcare plans offering financial assistance as part of the Affordable Care Act (ACA) will be conducted by the Health and Human Services Office of Inspector General (OIG), according to the Center for Public Integrity.

Audits of Medicare Advantage (MA) plans and healthcare plans offering financial assistance as part of the Affordable Care Act (ACA) will be conducted by the Health and Human Services Office of Inspector General (OIG), according to the Center for Public Integrity.

The new audit activities are outlined in OIG’s 2015 Work Plan, which details ongoing efforts to fight Medicare and Medicaid fraud and abuse.

MA plans are private plans that provide Medicare Parts A and B benefits to qualified enrollees, according to OIG.  Medicare establishes payments per beneficiary to deliver a specified set of health care benefits. The agency says that MA plans “pose a significant vulnerability for CMS and cost taxpayers billions of dollars.” In fiscal year 2013, OIG estimated that improper MA payments totaled almost $11.8.

According to the plan, “Efforts for FY 2015 and beyond may include additional work examining the soundness of rates and risk” of MA plans.

The large influx of newly insured under the ACA’s Medicaid expansion initiative has also prompted the OIG to look more closely at that program. “Protecting an expanding Medicaid program from fraud, waste, and abuse takes on a heightened urgency,” the OIG wrote. 

The audits will take a look at state Medicaid claims for federal reimbursement, state payments to managed care entities, program integrity in managed care, and completeness and accuracy of managed care encounter data, among others.

It will also be conducting a Risk Assessment of CMS' piolot Pioneer Accountable Care Organization model.

The OIG “conducts and coordinates criminal, civil, and administrative investigations of fraud, waste, abuse, and misconduct related to more than 100 Department of Health and Human Services (HHS) programs and operations,” according to the plan.

In fiscal year 2014, the agency recovered nearly $834.7 million in audit receivables and about $4.1 billion in investigative receivables, including about $1.1 billion in non-HHS investigative receivables from areas such as states’ Medicaid restitution.