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.

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:

1. Changing the incentives that drive fraud, waste, and abuse;
   
2. Making it more difficult to implement fraudulent, abusive, or wasteful activities; and
   
3. Using enforcement activities to deter and ensure accountability for instances of fraud, waste, and abuse.

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.

This work was funded by Arnold Ventures.