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Medicare Advantage audit rules could result in clawbacks from insurers

Posted On: Jan. 25, 2023 10:11 AM CST

The nation's largest health insurers are gearing up for upcoming changes to Medicare Advantage risk adjustment rules that could collectively cost them up to $3 billion in returned payments, Bloomberg reported Jan. 24, according to Becker’s Payer Issues. To date, nearly every major insurer has been accused of exploiting the program through elaborate "upcoding" schemes that make patients appear sicker on medical records than they are – thereby leading to higher payments from the Centers for Medicare & Medicaid Services.