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According to the OIG, $ 2.6 billion was paid out as part of the MA risk adjustment with low encounter data : HEALTH-CARE

Diving letter:

  • Medicare Advantage health plans billed the federal government $ 2.6 billion in 2016 for more than 617,000 patients whose risk-adjusted conditions were diagnosed without their doctor’s presence report closes from the HHS inspector general’s office.
  • In addition, the OIG report showed that 80% of these health risk assessments took place in a patient’s home, and were often done by providers hired by the healing plan as opposed to their actual doctor. In fact, more than 12,000 patients were declared risk-adjusted but received no further medical services in the calendar year. OIG warned that such practices could deprive patients with chronic illnesses who urgently need coordinated care.
  • In response to the report, CMS said it will oversee the 30 health plans most responsible for such charges. However, it opposed several other recommendations from OIG, including establishing best practices for performing in-home diagnoses and mandatory health plans to flag encounters where patients received in-home diagnoses.

Dive Insight:

CMS has advocated coordinated, value-based care for Medicare’s most vulnerable participants for years, but some MA health plans don’t always practice this philosophy.

According to Thursday’s report, more than 617,000 participants in MA plans were diagnosed with problems such as depression, vascular disease, and diabetes in 2016, but they were managed by a provider other than their own doctor. Despite a seemingly delicate form of diagnosis, this justified the plans for additional payments from Medicare as part of its risk-adjusted program. In one case, the health plan collected more than $ 50,000 in additional payments for a single patient in a single year.

More than 460 Medicare Advantage plans addressed this practice in 2016. However, nearly half of the money went to just 10 unidentified insurers, which together brought in $ 1.2 billion in risk-adjusted payments without their participants seeing their own doctor.

In addition, $ 60.9 million was paid out for more than 12,000 patients who had received no other medical benefits in 2016. According to the OIG report, 20 unidentified MA health plans were involved in those payments totaling nearly $ 44 million.

The department’s findings appear to be in line with a report released last month that concluded that many MA plans are not collecting enough encounter data to prevent fraud.

The Medicare Payment Advisory Commission reported such practices four years ago, but CMS took no action at that time.

OIG made five recommendations to correct the situation: Establish best practices for in-home diagnostics; Establish targeted monitoring of the 10 plans that generated the most payments; Establish targeted monitoring of the 20 plans that received payments without patients receiving further medical benefits in 2016; reassess the risk and benefit of such a diagnosis at home; and mark such diagnoses in encounter dates.

CMS said it would do the targeted monitoring of the 30 health plans but declined the other recommendations, saying the health plans were in the best position to decide how to share home-based diagnostic data and that it would not do the notification wanted to. and comment process behind the rule-making because “currently no regulatory medium is available”.

In a relatively infrequent pushback, OIG maintained its recommendation to establish best practices for home risk assessments because it “questions how effectively Medicare Advantage organizations use health risk assessments to coordinate care for … beneficiaries”.

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