Centers for Medicare & Medicaid Services (CMS) - Medicare Advantage (Part C)

High-priority program

Home > Agencies & Programs > Centers for Medicare & Medicaid Services (CMS) - Medicare Advantage (Part C)

Program level Payment Integrity results

Sponsoring agency: Department of Health and Human Services

Under the Medicare Advantage Program, also known as Medicare Part C, beneficiaries can opt to receive their Medicare benefits through a private health plan. Approximately half of all Medicare beneficiaries are enrolled in Medicare Advantage plans. The primary causes of overpayments are medical record discrepancies and insufficient documentation. Medicare Advantage Organizations are responsible for collecting and maintaining the documentation necessary to validate the data used in payment determinations. Medical records are not submitted to the agency at the time of making payment determinations.

View on Federal Program Inventory

PROGRAM METRICS

$225,604 M

in FY 2021 outlays, with a

89.7%

payment accuracy rate

PROGRAM METRICS

$257,174 M

in FY 2022 outlays, with a

94.6%

payment accuracy rate

PROGRAM METRICS

$275,606 M

in FY 2023 outlays, with a

94.0%

payment accuracy rate

PROGRAM METRICS

$339,932 M

in FY 2024 outlays, with a

94.4%

payment accuracy rate

PROGRAM METRICS

$388,717 M

in FY 2025 outlays, with a

93.9%

payment accuracy rate

  • Improper payment estimates over time
    View as:

    Chart toggle amounts:
    Proper payments
    Overpayment
    Underpayment
    Technically improper
    Unknown

Payment Integrity results

  • FY 2021 improper payment estimates

    Chart legend and breakdown

    Payment accuracy rate

    Improper payment rate

    Unknown payment rate


    Sampling & estimation methodology details

    Sampling timeframe:

    01/2019 - 12/2019


    Confidence interval:

    >95%


    Margin of error:

    +/-2638.56

Overpayments

Overpayment root cause Overpayment amount
Amount of overpayments within the agency's control $0.0 M

Overpayment root cause Overpayment amount
Amount of overpayments outside the agency's control $15,182.2 M
Amount of overpayments that occurred because the data/information needed to validate payment accuracy prior to making a payment does not exist $0.0 M
The amount of overpayments that occurred because of an inability to access the data/information needed to validate payment accuracy prior to making a payment $0.0 M
The amount of overpayments that occurred because of a failure to access data/information needed to validate payment accuracy prior to making a payment $15,182.2 M

Underpayments

Underpayment root cause Underpayment amount
Amount of underpayments $8,005.86 M
The amount of underpayments that occurred because the data/information needed to validate payment accuracy prior to making a payment does not exist $0.0 M
The amount of underpayments that occurred because of an inability to access the data/information needed to validate payment accuracy prior to making a payment $0.0 M
The amount of underpayments that occurred because of a failure to access data/information needed to validate payment accuracy prior to making a payment $8,005.86 M

Technically improper payments

The amount of improper payments that were paid to the right recipient for the correct amount but were considered technically improper because of failure to follow statute or regulation $0.0 M

Additional information

$8,005.86 M

Unknown Payment Details

Evaluation of corrective actions

Annually, the agency identifies the root causes of IPs and UPs and develops specific corrective actions to address them. This work is reported on through the AFR process.

Future payment integrity outlook

Centers for Medicare & Medicaid Services (CMS) - Medicare Advantage (Part C) has established a baseline.

Out-Year improper payment and unknown payment projections and target
Current year +1 estimated future outlays $433,699 M
Current year +1 estimated future improper payments $42,025.43 M
Current year +1 estimated future unknown payments $0 M
Current year +1 estimated future improper payment and unknown payment rate 9.69 %

The program's current year improper payment and unknown payment rate of 10.28 % has not been achieved with a balance of payment integrity risk and controls and does not represent the lowest rate that can be achieved without disproportionally increasing another risk, therefore it is not the tolerable rate.

A tolerable rate has not been established for this program.

A tolerable rate has not been established for this program.

Additional programmatic information

  • FY 2022 improper payment estimates

    Chart legend and breakdown

    Payment accuracy rate

    Improper payment rate

    Unknown payment rate


    Sampling & estimation methodology details

    Sampling timeframe:

    01/2020 - 12/2020


    Confidence interval:

    95% to <100%


    Margin of error:

    +/-0.7

Overpayments

Overpayment root cause Overpayment amount
Amount of overpayments within the agency's control $0 M

Overpayment root cause Overpayment amount
Amount of overpayments outside the agency's control $12,686.06 M
Amount of overpayments that occurred because the data/information needed to validate payment accuracy prior to making a payment does not exist $0.0 M
The amount of overpayments that occurred because of an inability to access the data/information needed to validate payment accuracy prior to making a payment $0.0 M
The amount of overpayments that occurred because of a failure to access data/information needed to validate payment accuracy prior to making a payment $12,686.06 M

Underpayments

Underpayment root cause Underpayment amount
Amount of underpayments $1,254.76 M
The amount of underpayments that occurred because the data/information needed to validate payment accuracy prior to making a payment does not exist $0.0 M
The amount of underpayments that occurred because of an inability to access the data/information needed to validate payment accuracy prior to making a payment $0.0 M
The amount of underpayments that occurred because of a failure to access data/information needed to validate payment accuracy prior to making a payment $1,254.76 M

Technically improper payments

The amount of improper payments that were paid to the right recipient for the correct amount but were considered technically improper because of failure to follow statute or regulation $0.0 M

Additional information

$1,254.76 M

Unknown Payment Details

Evaluation of corrective actions

The program is taking the following steps to ensure that managers, programs, and where appropriate, States and local governments are held accountable through annual performance appraisal criteria for meeting the program’s improper payment and unknown payment reduction target. Strengthening program integrity throughout HHS agencies and programs is a top priority of HHS, extending to each of our divisions and programs. As evidence of this focus, each accountable official’s performance plan contains strategic goals that are related to strengthening program integrity, protecting taxpayer resources, and reducing improper payments. The agency’s IP and UP reduction targets and progress towards meeting those goals are reported annually in the AFR. In addition, the agency sets annual GPRA goals related to the improper payment rates and reports quarterly on specific corrective actions to address improper payment rates through the quarterly scorecard process for high-priority programs.

Future payment integrity outlook

Centers for Medicare & Medicaid Services (CMS) - Medicare Advantage (Part C) has established a baseline.

CMS uses the reduction target to calculate the future IP+UP estimates; therefore, the Reduction target and IP+UP rate are equivalent for FY 2023. CMS expects the FY2023 rate to be statistically similar to the FY2022 rate, while considering the potential margin of error. In this, CMS sets a realistic goal to meet OMB thresholds while still considering historical rates and anticipated variance in the CY + 1 confidence intervals. Because CMS made significant methodology changes during the past two years' reporting (FY21 and FY22), CMS will treat FY2022 as a baseline and observe how the rate fluctuates over the next couple of years.

Out-Year improper payment and unknown payment projections and target
Current year +1 estimated future outlays $460,020 M
Current year +1 estimated future improper payments $26,543.15 M
Current year +1 estimated future unknown payments $0 M
Current year +1 estimated future improper payment and unknown payment rate 5.77 %
Current year +1 estimated future improper payment and unknown payment reduction target 5.77 %

The program's current year improper payment and unknown payment rate of 5.42 % may or may not be the tolerable rate. The agency has not yet determined the tolerable rate for this program.

Methodology to determine the tolerable rate for this program has not been determined.

A tolerable rate has not been established for this program. HHS is working within the current resources to perform the measurement of the Part C error rate calculation methodology.

A tolerable rate has not been established for this program. Budget submissions are to perform the measurement of the Part C error rate calculation within the current methodology.

Additional programmatic information

CMS implemented policy and methodology refinements to improve the accuracy of the payment error estimate and reflect improper payment measurement policy. These refinements contributed to a decrease in the projected Part C improper payment rate, representing a new baseline improper payment rate for Part C, therefore the 2022 Part C improper payment rate is not directly comparable with prior reporting years.

  • FY 2023 improper payment estimates

    Chart legend and breakdown

    Payment accuracy rate

    Improper payment rate

    Unknown payment rate


    Sampling & estimation methodology details

    Sampling timeframe:

    01/2021 - 12/2021


    Confidence interval:

    95% to <100%


    Margin of error:

    +/-0.75

  • Actions taken & planned to mitigate improper payments

    Mitigation strategy Description of the corrective action Completion date Status
    Training
    In March 2023, HHS held a Medicare Part C Fraud, Waste, and Abuse webinar covering the latest schemes, trends, data analysis, and investigations. The training featured presentations by law enforcement, plan sponsors, and program integrity contractors.
    FY2023 Q2
    Completed
    Audit
    Conducted contract-level RADV audits to verify the accuracy of enrollee diagnoses submitted by MAOs for risk-adjusted payments. Conducted audits of Part C plan sponsors to reduce improper payments and identify areas of non-compliance with PI.
    The corrective action was not fully completed this reporting period
    Not Completed
    Training
    HHS plans to hold additiional training on Medicare Part C Fraud, Waste, and Abuse covering the latest schemes, trends, data analysis, and investigations.
    FY2024
    Planned
    Audit
    HHS plans to continue conducting Risk Adjustment Data Validation (RADV) audits to address improper payments.
    FY2024
    Planned

Overpayments

Overpayment root cause Overpayment amount
Amount of overpayments within the agency's control $0 M

The primary causes of Medicare Advantage (Part C) improper payments are medical record discrepancies and insufficient documentation to determine whether payment was proper or improper. Medicare Advantage Organizations are the entities responsible for the maintenance and submission of accurate data for payment determinations, and attest to this upon submission. The MAO is also responsible for collecting and maintaining the source documentation (medical records) necessary to validate the data used in payment determinations. Medical records, the source document, are not submitted to the agency at the time of making payment determinations.
Overpayment root cause Overpayment amount
Amount of overpayments outside the agency's control $14,648.72 M
Amount of overpayments that occurred because the data/information needed to validate payment accuracy prior to making a payment does not exist $0.0 M
The amount of overpayments that occurred because of an inability to access the data/information needed to validate payment accuracy prior to making a payment $0.0 M
The amount of overpayments that occurred because of a failure to access data/information needed to validate payment accuracy prior to making a payment $14,648.72 M

Overpayment type Eligibility element/information needed Eligibility amount
Overpayments Outside Agency Control Medical Status $14,648.72 M

Underpayments

Underpayment root cause Underpayment amount
Amount of underpayments $1,902.04 M
The amount of underpayments that occurred because the data/information needed to validate payment accuracy prior to making a payment does not exist $0.0 M
The amount of underpayments that occurred because of an inability to access the data/information needed to validate payment accuracy prior to making a payment $0.0 M
The amount of underpayments that occurred because of a failure to access data/information needed to validate payment accuracy prior to making a payment $1,902.04 M

Eligibility element/information needed Eligibility amount
Medical Status $1,902.04 M

Mitigation strategies taken Mitigation strategies planned
Audit, Training Audit, Training

Technically improper payments

The amount of improper payments that were paid to the right recipient for the correct amount but were considered technically improper because of failure to follow statute or regulation $0.0 M

Additional information

$1,902.04 M

Unknown Payment Details

Evaluation of corrective actions

HHS continues to prioritize and implement effective corrective actions and mitigation strategies that reduce improper payments. The actions taken and planned to address the root causes of error, failure to access data, are proportional to the amount of improper payments (estimated at $16.55 billion in FY 2023) in the Medicare Advantage program. Contract-level RADV audits are HHS's primary strategy to recover Part C overpayments. RADV uses medical record reviews to confirm the accuracy of diagnoses submitted by Medicare Advantage Organizations (MAOs) for risk-adjusted payments. HHS also performs audits of MAOs to detect non-compliance with program integrity requirements, which can lead to additional improper payments. HHS also maintained formal outreach to MAOs for incomplete or invalid documentation to address potential improper payments during the sample submission period

Future payment integrity outlook

Centers for Medicare & Medicaid Services (CMS) - Medicare Advantage (Part C) has established a baseline.

HHS uses the reduction target to calculate the future IP+UP estimates; therefore, the Reduction target and IP+UP rate are equivalent for FY 2024. HHS expects the FY2024 rate to be within the range of statistically similar to the FY2023 rate; however, as FY2023 represents a new baseline HHS will observe how the rate fluctuates over the next couple of years.

Out-Year improper payment and unknown payment projections and target
Current year +1 estimated future outlays $432,362 M
Current year +1 estimated future improper payments $27,584.7 M
Current year +1 estimated future unknown payments $0 M
Current year +1 estimated future improper payment and unknown payment rate 6.38 %
Current year +1 estimated future improper payment and unknown payment reduction target 6.38 %

The program's current year improper payment and unknown payment rate of 6.01 % may or may not be the tolerable rate. The agency has not yet determined the tolerable rate for this program.

Methodology to determine the tolerable rate for this program has not been determined.

A tolerable rate has not been established for this program. The tolerable rate will be identified when the methodology is developed. Once the tolerable rate is developed, the agency can determine if we have what is needed with respect to internal controls, human capital and information system and other infrastructure to reduce Improper Payments and Unknown Payments to the tolerable rate.

A tolerable rate has not been established for this program. Once the tolerable rate is developed, the agency can determine if we have what is needed with respect to internal controls, human capital and information system and other infrastructure to reduce Improper Payments and Unknown Payments to the tolerable rate and we can describe the resources requested in the most recent budget submission to establish and maintain internal controls.

Additional programmatic information

The Reporting Year (RY) 2023 Medicare Part C improper payment rate is statistically similar to the RY 2022 Medicare Part C improper payment rate.

CMS is committed to strengthening and maintaining program integrity efforts to reduce improper payments rates. Contract-level RADV audits are HHS's primary strategy to recover Part C overpayments. RADV uses medical record reviews to confirm the accuracy of diagnoses submitted by Medicare Advantage Organizations (MAOs) for risk-adjusted payments. CMS also conducts program integrity audits and conducts outreach to plan sponsors for invalid or incomplete documentation.

  • FY 2024 improper payment estimates

    Chart legend and breakdown

    Payment accuracy rate

    Improper payment rate

    Unknown payment rate


    Sampling & estimation methodology details

    Sampling timeframe:

    01/2022 - 12/2022


    Confidence interval:

    95% to <100%


    Margin of error:

    +/-0.68

  • Actions taken & planned to mitigate improper payments

    Mitigation strategy Description of the corrective action Completion date Status
    Training
    In March 2024, HHS held a Medicare Part C Fraud, Waste, and Abuse webinar covering the latest schemes, trends, data analysis, and investigations. The training featured presentations by law enforcement, plan sponsors, and program integrity contractors. In June 2024, HHS held a Part C and Part D Fraud, Waste, and Abuse training in Dallas, Texas that covered information about current MAO and PDP fraud schemes, fraud prevention techniques, and activities that are critical to the efforts to deter and combat fraud, waste, and abuse. Additionally, the training provided a Program Integrity 101 course that focused on providing practical and actionable guidance to help continue combating Medicare fraud, waste, and abuse as well as an Information Sharing Session in which plan sponsors collaborated on case leads and promising practices. HHS also maintained formal outreach to plan sponsors for incomplete or invalid documentation to address potential improper payments during the sample submission period. Furthermore, HHS sent Final Findings Reports to all Part C sponsors participating in the improper payment measurement, offering feedback on their submissions and validation results compared to all participating sponsors.
    FY2024 Q4
    Completed
    Audit
    HHS conducts contract-level RADV audits to verify the accuracy of enrollee diagnoses submitted by MAOs for risk-adjusted payments. In FY24, HHS began developing a strategy to accelerate new RADV audits and finalizing previous audits.
    FY2024 Q4
    Completed
    Training
    HHS plans to hold additional trainings on Medicare Part C Fraud, Waste, and Abuse covering the latest schemes, trends, data analysis, and investigations.
    FY2025
    Planned
    Audit
    HHS plans to continue conducting RADV audits to address improper payments. HHS will also continue to develop a Part C strategy.
    FY2025
    Planned

Overpayments

Overpayment root cause Overpayment amount
Amount of overpayments within the agency's control $0.0 M

The primary causes of Medicare Advantage (Part C) improper payments are medical record discrepancies and insufficient documentation to determine whether payment was proper or improper. Medicare Advantage Organizations are the entities responsible for the maintenance and submission of accurate data for payment determinations, and attest to this upon submission. The MAO is also responsible for collecting and maintaining the source documentation (medical records) necessary to validate the data used in payment determinations. Medical records, the source document, are not submitted to the agency at the time of making payment determinations.
Overpayment root cause Overpayment amount
Amount of overpayments outside the agency's control $17,204.23 M
Amount of overpayments that occurred because the data/information needed to validate payment accuracy prior to making a payment does not exist $0.0 M
The amount of overpayments that occurred because of an inability to access the data/information needed to validate payment accuracy prior to making a payment $0.0 M
The amount of overpayments that occurred because of a failure to access data/information needed to validate payment accuracy prior to making a payment $17,204.23 M

Overpayment type Eligibility element/information needed Eligibility amount
Overpayments Outside Agency Control Medical Status $17,204.23 M

Underpayments

Underpayment root cause Underpayment amount
Amount of underpayments $1,862.68 M
The amount of underpayments that occurred because the data/information needed to validate payment accuracy prior to making a payment does not exist $0.0 M
The amount of underpayments that occurred because of an inability to access the data/information needed to validate payment accuracy prior to making a payment $0.0 M
The amount of underpayments that occurred because of a failure to access data/information needed to validate payment accuracy prior to making a payment $1,862.68 M

Eligibility element/information needed Eligibility amount
Medical Status $1,862.68 M

Mitigation strategies taken Mitigation strategies planned
Audit, Training Audit, Training

Technically improper payments

The amount of improper payments that were paid to the right recipient for the correct amount but were considered technically improper because of failure to follow statute or regulation $0.0 M

Additional information

$1,862.68 M

Unknown Payment Details

Evaluation of corrective actions

HHS continues to prioritize and implement effective corrective actions and mitigation strategies that reduce improper payments. The actions taken and planned to address the root causes of error, failure to access data, are proportional to the amount of improper payments (estimated at $19.07 billion in FY 2024) in the Medicare Advantage program. Contract-level RADV audits are HHS's primary strategy to recover Part C overpayments. RADV uses medical record reviews to confirm the accuracy of diagnoses submitted by Medicare Advantage Organizations (MAOs) for risk-adjusted payments. HHS also performs audits of MAOs to detect non-compliance with program integrity requirements, which can lead to additional improper payments. HHS also maintained formal outreach to MAOs for incomplete or invalid documentation to address potential improper payments during the sample submission period. HHS also plans to develop a Part C strategy.

As part of its efforts to ensure that the corrective actions are adequate, HHS continues to provide direction to MAOs on appropriate documentation and submission practices to substantiate medical diagnoses leverages compliance with program requirements.  These efforts will reduce medical record discrepancies. The error rate for Medicare Part C has dropped from 6.01% to 5.61%, which demonstrates the adequacy of HHS' corrective actions.

Underpayments are caused by MAO noncompliance with program requirements and insufficient documentation to support CMS HCCs for beneficiaries.  Continued direction and feedback to MAO organizations on appropriate documentation practices and submission requirements leverages positive results on payment errors.

As part of its efforts to ensure that the corrective actions are adequate, HHS continues to provide direction to MAOs on appropriate documentation and submission practices to increase compliance with program requirements.  These efforts will reduce medical record discrepancies. The error rate for Medicare Part C has dropped from 6.01% to 5.61%, which demonstrates the adequacy of HHS' corrective actions. 

Future payment integrity outlook

Centers for Medicare & Medicaid Services (CMS) - Medicare Advantage (Part C) has established a baseline.

HHS uses the reduction target to calculate the future IP+UP estimates; therefore, the Reduction target and IP+UP rate are equivalent for FY 2025. HHS expects the FY2025 rate to be within the range of statistically similar to the FY2024 rate; however, HHS will continue to observe how the rate fluctuates over the next couple of years.

Out-Year improper payment and unknown payment projections and target
Current year +1 estimated future outlays $541,902 M
Current year +1 estimated future improper payments $32,243.17 M
Current year +1 estimated future unknown payments $0 M
Current year +1 estimated future improper payment and unknown payment rate 5.95 %
Current year +1 estimated future improper payment and unknown payment reduction target 5.95 %

The program's current year improper payment and unknown payment rate of 5.61 % may or may not be the tolerable rate. The agency has not yet determined the tolerable rate for this program.

Methodology to determine the tolerable rate for this program has not been determined.

A tolerable rate has not been established for this program. The tolerable rate will be identified when the methodology is developed. Once the tolerable rate is developed, the agency can determine if we have what is needed with respect to internal controls, human capital and information system and other infrastructure to reduce Improper Payments and Unknown Payments to the tolerable rate.

To establish and maintain payment integrity internal controls in HHS included the following program integrity proposals in its FY 2026 Budget request:
• Expand Tools to Identify and Investigate Fraud in the Medicare Advantage Program
• Implement Targeted Risk-Adjustment Pre-payment Review in Medicare Advantage

Additional programmatic information

The Reporting Year (RY) 2024 Medicare Part C improper payment rate is statistically similar to the RY 2023 Medicare Part C improper payment rate.

Accountability for detecting, preventing, and recovering improper payments

HHS reports the agency’s improper payment targets annually in the AFR. In addition, HHS sets annual Government Performance and Results Act (GPRA) goals tied to reducing the improper payments. HHS executive officials are held accountable for assessing improper payment rates and taking meaningful steps to address the root causes of error. These efforts are reflected in each executive’s performance plan, as appropriate. HHS also reports quarterly on the specific actions taken to address the improper payment rates through the quarterly scorecard process for high-priority programs, providing a level of public oversight over these efforts.

  • FY 2025 improper payment estimates

    Chart legend and breakdown

    Payment accuracy rate

    Improper payment rate

    Unknown payment rate


    Sampling & estimation methodology details

    Sampling timeframe:

    01/2023 - 12/2023


    Confidence interval:

    95% to <100%


    Margin of error:

    +/-0.69

Causes

The primary causes of Medicare Advantage (Part C) improper payments are medical record discrepancies and insufficient documentation to determine whether payment was proper or improper. Medicare Advantage Organizations are the entities responsible for the maintenance and submission of accurate data for payment determinations, and attest to this upon submission. The MAO is also responsible for collecting and maintaining the source documentation (medical records) necessary to validate the data used in payment determinations. Medical records, the source document, are not submitted to the agency at the time of making payment determinations.

Overpayment root cause Overpayment amount
Amount of overpayments within the agency's control $0.0 M
Amount of overpayments outside the agency's control $21,434.34 M
Amount of overpayments that occurred because the data/information needed to validate payment accuracy prior to making a payment does not exist $0.0 M
Amount of overpayments that occurred because of an inability to access the data/information needed to validate payment accuracy prior to making a payment $0.0 M
Amount of overpayments that occurred because of a failure to access data/information needed to validate payment accuracy prior to making a payment $21,434.34 M

Underpayment root cause Underpayment amount
Amount of underpayments $2,230.78 M
The amount of underpayments that occurred because the data/information needed to validate payment accuracy prior to making a payment does not exist $0.0 M
The amount of underpayments that occurred because of an inability to access the data/information needed to validate payment accuracy prior to making a payment $0.0 M
The amount of underpayments that occurred because of a failure to access data/information needed to validate payment accuracy prior to making a payment $2,230.78 M

The amount of improper payments that were paid to the right recipient for the correct amount but were considered technically improper because of failure to follow statute or regulation $0.0 M

The amount that could either be proper or improper but the agency is unable to determine whether it was proper or improper as a result of insufficient or lack of documentation $0.0 M

Prevention

HHS is implementing corrective actions including health plan training, expanded  and accelerated contract-specific Risk Adjustment Data Validation (RADV) audits, and investigations to identify potential fraud and recover overpayments.
HHS continues to prioritize and implement effective corrective actions and mitigation strategies that reduce improper payments.  The actions taken and planned to address the root causes of error, failure to access data, are proportional to the amount of improper payments in the Medicare Advantage program. Contract-level RADV audits are HHS's primary strategy to recover Part C overpayments. RADV uses medical record reviews to confirm the accuracy of diagnoses submitted by Medicare Advantage Organizations (MAOs) for risk-adjusted payments. HHS also performs audits of MAOs to detect non-compliance with program integrity requirements, which can lead to additional improper payments. HHS also maintained formal outreach to MAOs for incomplete or invalid documentation to address potential improper payments during the sample submission period. HHS also plans to develop a Part C strategy.

As part of its efforts to ensure that the corrective actions are adequate, HHS continues to provide direction to MAOs on appropriate documentation and submission practices to increase compliance with program requirements.  These efforts will reduce medical record discrepancies. The error rate for Medicare Part C is 6.09%, which demonstrates the adequacy of HHS' corrective actions. 

Payment type Mitigation strategies taken Mitigation strategies planned
Overpayments Audit, Training Audit, Training
Underpayments Audit, Training Audit, Training

Eligibility element/information needed Description of the eligbility element/information
Medical Status Identifies whether a person is sick/healthy

Additional information

The Reporting Year (RY) 2025 Medicare Part C improper payment rate is statistically similar to the RY 2024 Medicare Part C improper payment rate.

Reduction target

6.43 %

A tolerable rate has not been established for this program. The tolerable rate will be identified when the methodology is developed. Once the tolerable rate is developed, the agency can determine if we have what is needed with respect to internal controls, human capital and information system and other infrastructure to reduce Improper Payments and Unknown Payments to the tolerable rate.

To establish and maintain payment integrity internal controls in HHS included the following program integrity proposals in its FY 2027 Budget request:

- Expand Tools to Identify and Investigate Fraud in the Medicare Advantage Program

HHS reports the agency’s improper payment targets annually in the AFR. In addition, HHS sets annual Government Performance and Results Act (GPRA) goals tied to reducing the improper payments. HHS executive officials are held accountable for assessing improper payment rates and taking meaningful steps to address the root causes of error. These efforts are reflected in each executive’s performance plan, as appropriate. HHS also reports quarterly on the specific actions taken to address the improper payment rates through the quarterly scorecard process for high-priority programs, providing a level of public oversight over these efforts. 

$2,230.78 M