Focus on Medicare Advantage (MA) Programs: Addressing DOJ Scrutiny

The Department of Justice (DOJ) continues to make investigating and prosecuting fraud within Medicare Advantage (MA) programs a priority. This increased focus is due to MA’s rapid growth and its complex billing system. Additionally, MA program enrollees include the elderly and disabled who are more susceptible to targeted scams and potentially less likely to identify fraudulent activity.

Some of the more common fraud and abuse schemes with MA programs are: 

• Risk Adjustment Abuse: Improper coding of diagnoses to inflate risk scores and receive higher payments.
• Skilled Nursing Facility (SNF) Stays: Unnecessary or prolonged stays in SNFs to generate higher revenue.
• Telehealth Fraud: Exploiting telehealth services for unnecessary consultations, billing for non-existent visits, or using telehealth to reach geographically dispersed patients for fraudulent schemes.
• Marketing Abuses: Misleading marketing tactics that target vulnerable populations or misrepresent program benefits.

Strong compliance programs that include internal audits, risk assessments, and employee training on fraud prevention are key. Additionally, organizations can:

• Ensure accurate and complete coding practices to avoid risk adjustment abuse.
• Establish clear criteria for SNF admissions and monitor the duration of stays to prevent unnecessary utilization.
• Create clear guidelines and protocols for telehealth services to minimize potential for fraud.
• Prioritize transparency in marketing materials related to the MA program and its eligibility criteria.
• Encourage open communication with beneficiaries to address concerns and foster a culture of compliance reporting.

By understanding how fraud might happen, whether intentionally or inadvertently, and implementing sound practices, MA providers can proactively mitigate fraud risks and avoid potential DOJ scrutiny.