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Billions in estimated Medicare Advantage payments from diagnoses reported only on health risk assessments raise concerns
Billions in estimated Medicare Advantage payments from diagnoses reported only on health risk assessments raise concerns
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Report in brief (United States. Department of Health and Human Services. Office of Inspector General)
- Contributor(s):
- United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections, issuing body.
- Publication:
- [Washington, D.C.] : U.S. Department of Health and Human Services, Office of Inspector General, September 2020
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Fraud -- prevention & control
Government Regulation
Medicare Part C -- economics
Risk Adjustment -- economics
United States
United States. Department of Health and Human Services - Genre(s):
- Technical Report
- Abstract:
- Why OIG Did This Review. We undertook this study because of concerns that MAOs may use HRAs to increase risk-adjusted payments inappropriately. The MA program provided coverage to 23 million beneficiaries in 2019 at a cost of $264 billion. Unsupported risk-adjusted payments have been a major driver of improper payments in the MA program. CMS risk-adjusts payments by using beneficiaries’ diagnoses to pay higher capitated payments to MAOs for beneficiaries expected to have greater health care needs. This may create financial incentives for MAOs to make beneficiaries appear as sick as possible. For CMS to risk-adjust payments, MAOs report beneficiaries’ diagnoses—based on services provided to beneficiaries—to CMS’s MA encounter data system and the Risk Adjustment Processing System. HRAs are an allowable source of diagnoses for risk adjustment. An HRA occurs when a physician or other health care professional collects information from beneficiaries about their health to diagnose and identify gaps in care. However, CMS and the Medicare Payment Advisory Commission have raised concerns that MAOs may use HRAs mainly as a tool to collect diagnoses and increase payments to MAOs rather than to improve the health of beneficiaries. How OIG Did This Review. We analyzed 2016 MA encounter data to determine the 2017 financial impact of diagnoses that were reported only on HRAs and not on any other service records in the encounter data that year. We also analyzed CMS responses to a structured questionnaire to identify actions taken by CMS to review the impact of HRAs on MA payments. What OIG Found. Our findings highlight concerns about the extent to which MAOs are using HRAs to improve care and health outcomes, as intended, and about the sufficiency of the oversight by the Centers for Medicare & Medicaid Services (CMS). From our analysis of 2016 MA encounter data, we found that: (1) Diagnoses that MAOs reported only on HRAs, and on no other encounter records, resulted in an estimated $2.6 billion in risk-adjusted payments for 2017. (2) In-home HRAs generated 80 percent of these estimated payments. Most in-home HRAs were conducted by companies that partner with or are hired by MAOs to conduct these assessments—and therefore are not likely conducted by the beneficiary’s own primary care provider. (3) Twenty MAOs generated millions in payments from in-home HRAs for beneficiaries for whom there was not a single record of any other service being provided in 2016. These findings raise three types of concerns: (1) a data integrity concern that MAOs are not submitting all service records as required; (2) a care coordination concern that beneficiaries are not receiving followup care to address diagnoses identified during HRAs; and (3) a payment integrity concern that if diagnoses are inaccurate or unsupported, the associated risk-adjusted payments would then be inappropriate. Despite potential issues regarding HRAs, CMS has not yet reviewed the impact of HRAs on risk-adjusted payments or quality of care.
- Copyright:
- The National Library of Medicine believes this item to be in the public domain. (More information)
- Extent:
- 1 online resource (1 PDF file (41 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 9918282481106676 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/9918282481106676