Medicare officials say more reforms are coming.
“While the Administration values the work that Medicare Advantage plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients,” Medicare administrator Dr. Mehmet Oz said in a statement earlier this year.
But it’s too soon to say whether the push, including expanded audits, will work.
Dr. Mehmet Oz leads the Centers for Medicare and Medicaid Services, shown here in March 2025. Oz has said he is “committed to crushing fraud, waste and abuse across all federal healthcare programs” including Medicare Advantage. (Ben Curtis/The Associated Press)
How it all started
In Medicare Advantage, seniors opt to receive Medicare benefits through private insurance companies. As part of the program, Congress created a mechanism that allowed insurers to receive additional payments for covering sicker patients.
When the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services launched its first six audits on risk adjustment more than a decade ago, two reports focused on a UnitedHealth subsidiary based in California, PacifiCare, where the insurer’s documentation didn’t support the submitted risk score data for dozens of seniors.
In one example, the company submitted the diagnosis code for peripheral vascular disease to support one patient’s risk score. But auditors found documentation didn’t mention the disease — it described, instead, the patient’s pain after a heavy can fell on her foot.