In the past:
When the OIG did audits on fraud for Medicare Advantage for the past several years, the literal definition of fraud in their reviews was to have a code in the RAPS payment system that was not the one in the actual medical record of the patient… [and] they estimated in a couple of reports that the fraud level using that definition … would be as much as 6 percent of the total Medicare Advantage spend.
The fee-for-service Medicare fraud level ranges from 6–7 percent, so the people looking at both numbers said that the plans and the caregivers were in the same ball park….
CMS [has] eliminated the plan opportunity to code. They killed the decades old RAPS system and they now get their diagnosis information on each patient from encounter reports that are filed on each Medicare Advantage member at each point of care.
The data from those encounter reports is accurate, dependable, and very real …. They don’t interpret or code anything with the new approach. The encounter reports use the medical records to get each diagnosis.
As a result:
The Medicare Advantage fraud level for 2022 … will be very close to zero.