Sarah M. Hall, Member of the Firm in the Health Care & Life Sciences practice, in the firm’s Washington, DC, office, was quoted in Bloomberg Health Law & Business, in “Trump’s Focus on Medicare Advantage Fraud Poses Enforcement Test,” by Holly Barker. (Read the full version – subscription required.)
Following is an excerpt:
The Trump administration has vowed to ferret out Medicare Advantage fraud, but keeping that promise will mean overcoming challenges that have stymied Justice Department investigations for years.
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Under the Medicare Advantage program, or Medicare Part C, the Centers for Medicare & Medicaid Services contracts with private plan administrators to provide Medicare coverage.
Those plan administrators receive, for each beneficiary, a fixed payment that’s risk adjusted to approximate the projected cost of the patient’s care.
More than half of the eligible Medicare population opted to enroll in such plans in 2024, according to KFF. Their care accounted for more than $460 billion of total Medicare spending. …
Risk-adjustment fraud occurs when a patient’s diagnoses are misrepresented in order to inflate those payments, a practice that has cost US taxpayers billions, according to CMS and the Office of Inspector General for the Health and Human Services Department.
With those dollar figures at stake and MA payments only set to increase, there are multiple data points indicating a current enhanced federal scrutiny of MA plan administrators, said Sarah Hall, a partner with Epstein Becker & Green PC and a former federal prosecutor.
At his March confirmation hearing, CMS Administrator Dr. Mehmet Oz committed to scrutinizing MA plans. The agency has since announced that it’s enhancing its risk-assessment auditing process.
And senior officials from the DOJ’s civil division have said the agency intends to aggressively enforce the False Claims Act, highlighting MA fraud as a priority.
“The Justice Department under Trump has really gotten behind the FCA, which probably dovetails well with the push to investigate Medicare Advantage fraud,” Hall said.
“Investigators can look at data all day long,” she said. “With the help of whistleblowers, they can unpack complex schemes in a much more expedient way.”
