Episode 191: Participation loopholes in Medicare Advantage

OIG Roundtable (Formerly Retro Fraud)

Episode 191: Participation loopholes in Medicare Advantage

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MA plans are not required to reject claims from non-participating providers, while traditional Medicare requires providers to be enrolled in order to submit claims. This creates a huge FWA opportunity as there is no real way to vet the provider and the claims since there is no contractual relationship between the provider and payor (unless some state law or regulation establishes such a relationship via the submission of the claim itself).