The federal government and health insurance companies have been clashing for more than a decade over how Medicare Advantage plans should be audited and how the well-documented overpayments to those plans should be clawed back.
That fight is about to hit an inflection point this week, when Medicare makes a final determination about how aggressively it will probe the industry. But experts say this is just the start of another brawl that almost certainly will shift into, and clog up, the courts for many more years.
Billions of dollars are on the line, almost all of which would get redirected back toward taxpayers and Medicare enrollees. But that large amount of money is also the major reason why there has been so much inertia. On one side sits an insurance industry hellbent on ensuring nosy auditors don’t touch its extremely profitable Medicare Advantage plans. On the other side exists an under-resourced federal oversight system that has become paralyzed by its own indecision and deference to that politically powerful industry.
“Everybody has blood on their hands,” said Richard Lieberman, CEO of health insurance data analytics firm Cortex Analytics who has more than 30 years of experience with risk adjustment. “This is not an industry problem independent of everyone. This is not a [Centers for Medicare and Medicaid Services] problem independent of everyone. Everyone has contributed to this.”