The HHS first proposed the rule to conduct audits of MA payers in 2018 and finalized it in January.
The government expects to claw back roughly $4.7 billion over the next decade by recouping payments from cases where payers inflated patients’ sickness to garner higher reimbursement from the government.
Overpayment is a huge issue in the MA program, where private insurers receive lump sums from the government to cover the care of Medicare seniors. Plans receive more money for sicker patients, creating an incentive for plans to plans to inflate risk scores.
