Archive

Medicare Part C: Fighting Back Against Risk Adjustment Fraud

Health insurance companies that participate in the Medicare Managed Care program (also known as Medicare Advantage or Medicare “Part C”) routinely complain about cuts to their reimbursement rates – even in years, like this one, where the reimbursement rates are actually increased.  At the same time, reports indicate that insurers are “leaning heavily on their Medicare business” and “signal[ing their]...

In Their Own Words -- Sparrow

-- "It shows the incentives provided for whistleblowers are working well, and all the other controls and detection systems are failing miserably."

Malcolm Sparrow, a health care fraud expert at Harvard's John F. Kennedy School of Government, on the increasing number of whistleblower actions challenging fraud in the Medicare Advantage healthcare program.  Click here for more.

GAO Report Finds Medicaid Managed Care Vulnerable To Fraud

By Marlene Koury A new study conducted by the US Government Accountability Office ("GAO") shows that the Medicaid managed care program is vulnerable to serious health care fraud.  The study found that the weakness is primarily due to the Centers for Medicare and Medicaid Services ("CMS") delegating managed care oversight to the states – but without providing them with clear guidance and resources to combat...