HealthcareDive.com 4 Feb 2023:
Federal regulators likely will claw back billions of dollars [paid to] Medicare Advantage plans [calculated from] 2018, backtracking from an earlier proposal that … had proposed to [reach as far as 2011 on overpayments to] health insurers that operate Medicare Advantage plans, which cover about 29 million Americans.
A key change [from earlier correction proposals]: regulators will extrapolate from a small subset of audits and apply the error rate to the insurer’s Medicare Advantage business….
UPDATE: Beckers 50 States & WashDC ranked by total Medicare Advantage members: “Eight have at least 1 million residents each enrolled in MA plans, according to a health coverage report published by insurance trade group AHIP in April[2023].”
<small>FOR BACKGROUND</small> see Advantage plans defrauded Medicare $11billion+ in 2022 alone and DK tag for diaries about or including MedicareAdvantage as a topic, also other tags in left margin.
For years, federal regulators had voiced payment abuse concerns. but with no significant audit or financial deterrents to rein excesses in. Among the factors, risk-adjusted scores for raising payments for Advantage plans sicker members (e.g., chronically ill and disabled elders) which federal regulators found only incentivizing plans to “game the system.” — the HHS Office of Inspector General (OIG) has flagged the use of health risk assessments used by plans to collect member information for boosting risk scores.
A previous OIG report said that by CMS’ own estimates, Medicare made $50 billion in overpayments from 2013 through 2017 [based on] “from plan-submitted diagnoses that were not supported by beneficiaries’ medical records.”
Health-med insurance industry groups such as AHIP (formerly America's Health Insurance Plans) and the Better Medicare Alliance have dismissed newly released data as “misleading” and “more than a decade old” as if time has made earlier fraud irrelevant. But it took a three-year Freedom of Information lawsuit alone by KHN to make key data public. This while Medicare Advantage plans have faced mounting criticism
from government watchdogs and in Congress, the industry has tried to rally seniors to its side while disputing audit findings and research that asserts the program costs taxpayers more than it should.
As the correction process begins, a Medicare Advantage milestone is expected this year: more seniors enrolled in MA plans than in traditional fee-for-service Medicare.
<big>FROM CMS EMAIL Monday JANUARY 30, 2023</big>
Today, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), finalized the policies for the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program, which is CMS’s primary audit and oversight tool of MA program payments. Under this program, CMS identifies improper risk adjustment payments made to Medicare Advantage Organizations (MAOs) in instances where medical diagnoses submitted for payment were not supported in the beneficiary’s medical record. The commonsense policies finalized in the RADV final rule (CMS-4185-F) will help CMS ensure that people with Medicare are able to access the benefits and services they need, including in Medicare Advantage, while responsibly protecting the fiscal sustainability of Medicare and aligning CMS’s oversight of the Traditional Medicare and MA programs.
As required by law, CMS’ payments to MAOs are adjusted based on the health status of enrollees, as determined through medical diagnoses reported by MAOs. Studies and audits done separately by CMS and the HHS Office of Inspector General (OIG) have shown that Medicare Advantage enrollees’ medical records do not always support the diagnoses reported by MAOs, which leads to billions of dollars in overpayments to plans and increased costs to the Medicare program as well as taxpayers. Despite this, no risk adjustment overpayments have been collected from MAOs since Payment Year (PY) 2007.
“Protecting Medicare is one of my highest responsibilities as Secretary, and this commonsense rule is a critical accountability measure that strengthens the Medicare Advantage program. CMS has a responsibility to recover overpayments across all of its programs, and improper payments made to Medicare Advantage plans are no exception,” said HHS Secretary Xavier Becerra. “For years, federal watchdogs and outside experts have identified the Medicare Advantage program as one of the top management and performance challenges facing HHS, and today we are taking long overdue steps to conduct audits and recoup funds. These steps will make Medicare and the Medicare Advantage program stronger.”
“CMS is committed to protecting people with Medicare and being a responsible steward of taxpayer dollars,” said CMS Administrator Chiquita Brooks-LaSure. “By establishing our approach to RADV audits through this regulation, we are protecting access to Medicare both now and for future generations. We have considered significant stakeholder feedback and developed a balanced approach to ensure appropriate oversight of the Medicare Advantage program that aligns with our oversight of Traditional Medicare.”
The RADV final rule reflects CMS’s consideration of extensive public comments and robust stakeholder engagement after the release of the 2018 Notice of Proposed Rulemaking. The finalized policies will also allow CMS to continue to focus its audits on those MAOs identified as being at the highest risk for improper payments.
The RADV final rule can be accessed at the Federal Register here: https://www.federalregister.gov/public-inspection/2023-01942/medicare-and-medicaid-programs-policy-and-technical-changes-to-the-medicare-advantage-medicare
View the fact sheet on the final rule here: https://www.cms.gov/newsroom/fact-sheets/medicare-advantage-risk-adjustment-data-validation-final-rule-cms-4185-f2-fact-sheet.
RELATED, because what is it we and CMS are paying for?
Medscape — 31Jan2023 <big>The U.S. spends dramatically more on health care than other high-income nations but has the worst health outcomes on nearly every metric.</big>
..."Americans are living shorter, less healthy lives because our health system is not working as well as it could be," said report author Munira Gunja, according to CNN. "To catch up with other high-income countries, the administration and Congress would have to expand access to health care, act aggressively to control costs, and invest in health equity and social services we know can lead to a healthier population."
Published Tuesday by The Commonwealth Fund, the report [compares] the U.S... to other high-income countries ... such as Australia, Canada, Germany, Japan, South Korea, and the United Kingdom. The U.S. was the only country in the study that does not guarantee health coverage [and the authors] said the country's health system seems "designed to discourage people from using services." ... ...affordability of health care was the top reason Americans gave for skipping or delaying care [although] 30% of adults have multiple chronic conditions …
The U.S. had the worst rates among 12 peer countries studied for life expectancy, death due to assault, avoidable deaths, infant and maternal mortality, and obesity. One of the only metrics ... in which the U.S. did not have the worst outcomes ... was in suicide rates. The U.S. ranked third [after] Japan [and] South Korea...
and as previously established:
cms.gov...Office of Minority Health — April 2020 —<big>Racial, Ethnic, and Gender Disparities in Health Care in Medicare Advantage</big>
There’s a lot of hard work ahead of us.
__________________________________________________________________
btlawnews — Nov 17, 2022 Court rules U.S.' Medicare Advantage Suit Against Kaiser Permanente May Move Forward With nearly 13million patients nationwide, KP is the largest managed care provider in the U.S. See also: https://www.dailykos.com/tags/KaiserPermanente
The government alleges that Kaiser violated the False Claims Act (FCA) by submitting inaccurate diagnosis codes via addenda for its Medicare Advantage Plan enrollees in an effort to increase patients' risk scores and, as a result, receive higher reimbursements….