CMS agrees to release Medicare Advantage audits to settle lawsuit

The Centers for Medicare and Medicaid Services (CMS) has agreed to publicly release dozens of private Medicare Advantage health plan audits to settle a 2019 lawsuit filed by Kaiser Health News (KHN).

KHN in September 2019 filed a lawsuit asking that CMS provide 90 government audits, including documents from the years 2011, 2012 and 2013.

These documents were reviews of the Medicare Advantage Risk Adjustment Data Validation. Risk adjustment is used by health insurance providers to determine expected medical costs of enrolled individuals.

KHN argued in its lawsuit that CMS was improperly withholding audits of Medicare Advantage plans, with these reviews allegedly having identified more than $650 million in improper charges.

By settling the lawsuit, CMS did not admit to wrongfully withholding the requested documents and also agreed to pay $63,000 in legal fees, according to KHN. The agency will make “best efforts” to provide the documents over the next six weeks.

Medicare Advantage, also known as Medicare Part C, is largely run through contracted private insurance companies. Around the time that the lawsuit was filed in 2019, it had been reported that Medicare Advantage plans had overcharged the federal government by about $30 billion over the preceding three years, prompting scrutiny from both the media and lawmakers.

As of 2022, more than 28 million Medicare beneficiaries are enrolled in Medicare Advantage, accounting for nearly half of all beneficiaries.

These documents are expected to reveal hundreds of million of dollars in overcharges, KHN reported.

Thomas Burke, an attorney who represented KHN in the suit, said, “It’s incredibly frustrating that it took a lawsuit and years of pushing to make this vital information public.”

The Hill has reached out to CMS for comment.