Health Insurers Gird for Audits of Medicare Managed Care Claims

A rule to recover billions of dollars in overpayments to Medicare managed care plans is drawing the ire of health insurers who say its lack of a “fee-for-service adjustment” in determining the repayment amounts is both unfair and unlawful.

The adjustment was expected to reduce the amount of excess payments that Medicare would recoup. It would have accounted for the difference in documentation standards used to determine patient diagnoses in traditional, fee-for-service Medicare and the private Medicare Advantage plans, which the rule targets.

Medicare’s plan to forgo the adjustment drew strong opposition from America’s Health Insurance Plans when the rule ...