Waste and Fraud

CMS Administrator Seema Verma may not be fit to run the agency during the pandemic after rejecting an HHS Office of Inspector General report released Thursday (July 16) that found she inappropriately used communication contractors to direct federal employees and make key decisions, key congressional Democrats say.

A federal appeals court should revive a controversial overpayment rule in Medicare Advantage because, without the rule in place, CMS has limited ability to stop MA plans from engaging in one-sided medical reviews that artificially inflate their payments, the agency says in a recent legal brief.

Anthem Inc. fraudulently overcharged CMS by millions of dollars in Medicare Advantage payments by failing to correct inaccurate diagnosis data, federal prosecutors allege in a lawsuit against the company.

The HHS Office of Inspector General plans to look at whether state Medicaid agencies are incorrectly paying Medicaid managed care plans for beneficiaries that have moved to a different state and may be part of two different Medicaid programs, but the head of the National Association of Medicaid Directors says it’s not clear why OIG is taking this up now since the payments have been relatively minor and the issue has been going on for some time.

The Medicare fee-for-service improper pay rate dropped again, according to the HHS fiscal 2019 financial report, dipping below the Medicare Advantage improper pay rate -- though that program’s improper pay rate dropped too, as did the Medicare Part D improper pay rate.

CMS on Monday (Oct. 21) again asked about the best ways to use prior authorization – this time with a focus on using such policies to improve Medicare payment accuracy – and said it is also looking at how artificial intelligence could improve payments.

Illinois improperly paid Medicaid managed care plans on behalf of beneficiaries who were deceased, according to a new report from the HHS Office of Inspector General that is the latest in a series of audits that found at least eight states have issued Medicaid payments on behalf of dead people.

CMS on Thursday (June 20) released guidance that makes clear CMS’ expectations for how states should make sure they correctly determine Medicaid eligibility for the expansion population after lawmakers raised concerns following recent audits from the Office of Inspector General and others that found some states did not correctly determine eligibility.

CMS is auditing California, Kentucky and New York — and will soon begin an audit of Louisiana — following reports that those states incorrectly determined Medicaid eligibility for some beneficiaries who received coverage through the Affordable Care Act’s Medicaid expansion, CMS Administrator Seema Verma said in a letter to Senate Finance Committee leaders.