Inspector General’s Report Raises Red Flags Over Billions In Medicare Advantage Payments To Private Insurers
An Inspector General report suggests that private insurers are combing through patients' files and adding on conditions like diabetes to make the patient looks sicker than they were to get more money from the government. A spokeswoman for America's Health Insurance Plans said the report is based on a type of data with well-documented challenges, and noted that the watchdog didn't review medical records for the analysis.
The New York Times:
Federal Watchdog Questions Billions Of Dollars Paid To Private Medicare Plans
A government report released Thursday found health insurance companies had combed through patient charts to obtain billions of dollars of additional payments from the federal Medicare program. The report, from the federal inspector general’s office, examined payments billed by insurers for those covered by private Medicare Advantage plans, which are increasingly popular and heavily promoted by the Trump administration. The findings showed that insurers were adding on conditions like diabetes and even cancer, reporting that patients were sicker, to receive higher payments from Medicare. (Abelson, 12/12)
Politico Pro:
HHS OIG Says Medicare Advantage Plans Collected $6.7B In Improper Payments
The OIG flagged that insurers, in more than 99 percent of cases, added diagnoses of serious conditions like diabetes and vascular disease to their enrollees' medical charts even when the clinician records didn't justify it. They deleted diagnoses less than 1 percent of the time. The OIG said it’s not just concerned about the accuracy of the data the plans use to bill the government: If patients are as seriously sick as the insurers say, doctors’ own records aren’t showing they get the care they need. The OIG reviewed only patient data from 2016. Insurers pointed out that the auditors didn't look at patients' full medical history. (Luthi, 12/12)
Modern Healthcare:
Chart Reviews Boost Medicare Advantage Payments By $6.7 Billion
"Chart reviews can be a tool to improve the accuracy of risk-adjusted payments by allowing (Medicare Advantage organizations) to add and delete diagnoses in the encounter data based on reviews of patients' records," the OIG wrote. "However, chart reviews—particularly those not linked to service records—may provide MAOs opportunities to circumvent the Centers for Medicare & Medicaid Services' face-to-face requirement and inflate risk-adjusted payments inappropriately." (Livingston, 12/12)
On other news on CMS and Medicare —
Modern Healthcare:
CMS To Repay Hospitals For Doctor's Visits
The CMS Thursday said it will pay hospitals the money it owes them for doctor's visits in 2019. A federal judge ruled in September that the Trump administration had exceeded its authority when it implemented its so-called site-neutral payment at off-campus hospital clinics. The American Hospital Association, which filed the lawsuit, estimated that the policy cost providers about $380 million in 2019. U.S. District Judge Rosemary Collyer in Washington did not require the CMS to repay the funds at the time, instead asking the AHA and the CMS to file a joint status report. The CMS' decision is a big win for hospitals. (Brady, 12/12)
Modern Healthcare:
HCAHPS Isn't Enough To Measure Patient Experience, Report Finds
Hospitals that used a comprehensive approach to measuring their patients' experience saw better clinical outcomes and brand recognition than their peers that only used federal survey requirements, according to a new analysis. While the CMS' Hospital Consumer Assessment of Healthcare Providers and Systems survey is a valuable tool in assessing and improving care quality, patient experience management firm Service Management Group said healthcare organizations that establish their own measurement strategies were more likely to see improvement. (Johnson, 12/11)
The Wall Street Journal:
Medicare Enrollment Can Be Confusing And Lead To Unexpected Costs
As more Americans postpone retirement, a growing number are experiencing Medicare enrollment problems that can saddle them with hefty penalties and monthslong coverage gaps. The roots of the problem are Medicare’s complex rules and a lack of notice from the program explaining the steps older workers must take to enroll once they leave their jobs. In recent decades, Americans have remained in the workforce longer, for reasons including concerns about savings and a desire to keep working, with many putting off taking Social Security payments. (Tergesen, 12/12)
