Medicare Advantage Fraud, Waste, and Abuse Policy Options
By providing benefits through private plans, the Medicare Advantage program has the potential to make care delivery more efficient and to reduce costs through market competition and innovation. Medicare Advantage addresses some challenges faced by Traditional Medicare.
However, the Medicare Advantage approach of paying plans a capitated amount to deliver Medicare benefits in lieu of the government paying for care directly presents some oversight challenges and some fraud, waste, and abuse risks that differ from Traditional Medicare.
These risks can lead to increased program costs, burden for providers, reduced access to care, poor-quality care, and in some cases, direct harm to enrollees.
Susan Joy
Managing Director
Our research shows that there are significant fraud, waste, and abuse risks in Medicare Advantage. We also found that there are many options for policy and program reform as well as enforcement actions that decisionmakers can consider, and that could make a real difference in reducing fraud, waste, and abuse.
Susan Joy
Managing Director
AIR examined peer-reviewed and gray literature to identify policy options and oversight approaches to address risks for fraud, waste, and abuse in Medicare Advantage.
AIR found that options encompassed:
- Changing the incentives that drive fraud, waste, and abuse;
- Making it more difficult to implement fraudulent, abusive, or wasteful activities; and
- Using enforcement activities to deter and ensure accountability for instances of fraud, waste, and abuse.
Exploring the Report
Each chapter in the full report discusses policy and oversight approaches to address fraud, waste, and abuse risks in a specific area. Additional chapters will be published over the coming months.
- Introduction and Methods
- Star Ratings and the Quality Bonus Program
- Network Adequacy and Misrepresentation of Provider Networks
- Cost Shifting to the Department of Veterans Affairs
- Enrollment, Agents, and Brokers
- Prior Authorization and Other Utilization Management Approaches
- Payer-Provider Vertical Integration
- Dual Eligible Special Needs Plan (D-SNP) Look-alikes
- Coding Intensity (coming soon)
- Favorable Selection (coming soon)
This work was funded by Arnold Ventures.
