OIG

OIG Strengthens Oversight Strategy for Managed Care Organizations

August 30, 2023 - Managed care organizations (MCOs) require the same kind of oversight that fee-for-service programs receive from the Office of Inspector General (OIG), so OIG released a four-phase life cycle to align its oversight efforts. A growing number of enrollees are covered through MCOs. Over eight in ten Medicaid beneficiaries have coverage through MCOs for...

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OIG Finds CMS Overpaid Geisinger Medicare Advantage Plan by Over $566K

by Kelsey Waddill

The Office of the Inspector General (OIG) found that most of the audited diagnosis codes that Geisinger Health Plan sent to CMS for its Medicare Advantage plan were non-compliant. The office audited...

OIG: Cigna Should Refund Feds $5.9M for Medicare Advantage Overpayments

by Kelsey Waddill

In its analysis of Cigna-HealthSpring of Tennessee’s risk adjustment program payments, the Office of Inspector General (OIG) found that 195 of the 279 unique enrollee-years did not have medical...

OIG: Medicaid Managed Care Plans Submit Incomplete MLR Reports

by Victoria Bailey

Almost half of medical loss ratio (MLR) reports from state Medicaid managed care plans were incomplete, indicating the need for CMS to increase states’ oversight of MLR reporting, the Office of...

AHIP Calls For More Accurate Federal Reporting on Medicare Advantage

by Kelsey Waddill

AHIP acknowledged the need for improved oversight for certain Medicare Advantage quality metrics but also argued that federal reporting on Medicare Advantage plans has been inaccurate in the...

OIG: Medicare Race, Ethnicity Data Is Inaccurate, Thwarts Health Equity

by Kelsey Waddill

The Office of Inspector General (OIG) has discovered that Medicare’s race and ethnicity data was less accurate for minority groups—particularly for those who identify as American Indian or...

OIG Suggests Changes to MA Prior Authorizations, Payment Requests

by Kelsey Waddill

Medicare Advantage plans have incorrectly denied or delayed prior authorizations or payment requests and, in doing so, have accrued unwarranted revenues, according to a report from the Office of...

OIG: CMS Should Promote Biosimilars To Reduce Part D Spending

by Kelsey Waddill

Policymakers should consider increasing access to and promoting the use of biosimilars and monitoring trends in biosimilar coverage in order to bring down Medicare Part D spending, the Office of...

OIG: Medicare Advantage Plans Improperly Used Chart Reviews, HRAs

by Victoria Bailey

Some Medicare Advantage plans may have improperly used chart reviews and health risk assessments to maximize risk-adjusted payments from CMS, a report from the Office of Inspector General...

MO Medicaid Home Healthcare Program Received Improper Payments

by Victoria Bailey

Missouri claimed $3.4 million in improper payments for its Medicaid home healthcare program providers and did not comply with federal and state Medicaid requirements, according to a report from the...

Chart Reviews Without Service Records May Cause Improper Payments

by Kelsey Waddill

The Office of the Inspector General’s (OIG’s) recent study on Medicare Advantage (MA) payments analyzed whether MA organizations are raising their risk-adjusted payment rates in reaction to...

OIG: CMS Spent $160.8 Million on Duplicate Medicare Spending

by Kelsey Waddill

The Office of Inspector General (OIG) audited Medicare spending and found that CMS spent $160.8 million paying for drugs that should have been covered by hospices. This data follows a 2012 OIG report...

BCBS of TN Defrauded $2M in $2B Telemedicine Insurance Scheme

by Thomas Beaton

BlueCross BlueShield (BCBS) of Tennessee has been named a damaged party after it was defrauded $2 million as part of a larger $2 billion telemedicine insurance scheme, according to the Department of...

$36.9M in Medicare Fraud Leads to Federal Convictions, Sentencing

by Thomas Beaton

New high-profile Medicare fraud cases have led to convictions and lengthy prison sentences for providers that attempted to defraud Medicare of $36.9 million. Federal agencies including HHS, the FBI,...

DaVita Medical to Pay $270M for Improper Medicare Advantage Payments

by Thomas Beaton

DaVita Medical Group has agreed to pay $270 million to the Medicare program after identifying suspect billing practices that incorrectly raised its Medicare Advantage payments, says the Department of...

OIG Finds Profits to Blame for Denied Medicare Advantage Claims

by Thomas Beaton

Fifty-six percent of Medicare Advantage (MA) payers inappropriately denied claims from beneficiaries and providers to potentially profit from the capitated payment system, according to a report from...

Commercial, Public Payer Healthcare Fraud Cases Total $21.6M

by Thomas Beaton

The latest string of commercial and public payer healthcare fraud cases totaled $21.6 million from providers launching various schemes such as patient kickback agreements and false claims...

DoJ Settles $27.68M in Medicare Fraud, False Claims Act Violations

by Thomas Beaton

The Department of Justice continues its crackdown on Medicare fraud by settling various criminal cases related to $27.68 million of False Claims Act violations. Provider settlements remain the primary...

OIG: Medicaid Fraud Control Units Recovered $1.8B in 2017

by Thomas Beaton

Medicaid fraud control units (MFCUs) recovered $1.8 billion in 2017 through effective collaboration with state governments, according a new report released by the Office of the Inspector General...

OIG: Medicare Could Save $367M by Auditing Improper Payments

by Thomas Beaton

CMS auditing systems failed to recognize that 61 percent of Medicare payments for outpatient physical therapy claims in 2013 were improperly filed, which cost the Medicare program nearly $367 million,...

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