CMS agrees to release Medicare Advantage audits to settle lawsuit

The Centers for Medicare and Medicaid Services (CMS) has agreed to release dozens of Medicare Advantage private health plan audits to settle a 2019 lawsuit filed by Kaiser Health News (KHN).

In September 2019, KHN filed a lawsuit asking CMS to provide 90 government audits, including documents from the years 2011, 2012 and 2013.

These papers were reviews of the validation of Medicare Advantage risk adjustment data. The risk adjustment is used by health insurance providers to determine expected medical costs for enrollees.

KHN argued in its lawsuit that CMS improperly withheld audits of Medicare Advantage plans, as those reviews allegedly identified more than $650 million in improper charges.

In settling the lawsuit, CMS did not admit to wrongfully withholding the requested documents and also agreed to pay $63,000 in legal fees, according to KHN. The agency will “do its best” to provide the documents within the next six weeks.

Medicare Advantage, also known as Medicare Part C, is largely managed by contracted private insurance companies. Around the time the lawsuit was filed in 2019, it was reported that Medicare Advantage plans had overbilled the federal government by approximately $30 billion in the previous three years, prompting scrutiny from from the media and legislators.

In 2022, more than 28 million Medicare beneficiaries are enrolled in Medicare Advantage, representing nearly half of all beneficiaries.

Those documents are expected to reveal hundreds of millions of dollars in overcharges, KHN reported.

Thomas Burke, an attorney who represented KHN in the lawsuit, said, “It’s incredibly frustrating that it took a trial and years of pressure to release this vital information.”

The Hill has contacted CMS for comment.

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