Some Medicare Advantage companies leveraged chart reviews and health risk assessments to disproportionately drive payments

Some Medicare Advantage companies leveraged chart reviews and health risk assessments to disproportionately drive payments

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 2021
Language(s):
English
Format:
Text
Subject(s):
Government Regulation
Health Status Indicators
Insurance Carriers -- legislation & jurisprudence
Medical Records -- economics
Medicare Part C -- economics
Quality of Health Care -- legislation & jurisprudence
United States
United States. Department of Health and Human Services
Genre(s):
Technical Report
Abstract:
Why OIG Did This Review. We undertook this evaluation because of concerns that companies with contracts under Medicare Advantage (MA companies) may leverage both chart reviews and health risk assessments (HRAs) to maximize risk-adjusted payments, without beneficiaries receiving care for those diagnoses. Unsupported risk-adjusted payments have been a major driver of improper payments in the MA program. The risk-adjustment program is an important payment mechanism for MA. It levels the playing field for MA companies that enroll beneficiaries who need a costlier level of care, which helps to ensure that these beneficiaries have continued access to MA plans. Chart reviews and HRAs can be tools for improving the MA program. However, two prior OIG evaluations found that the diagnoses that MA companies reported only on chart reviews or HRAs in the 2016 encounter data— i.e., on no other service records— resulted in billions in risk-adjusted payments for 2017. These prior evaluations raised concerns about the completeness of encounter data; the validity of submitted diagnoses on chart reviews or HRAs; and the quality of care provided to MA beneficiaries. The current evaluation builds on those two evaluations to identify MA companies that disproportionately drove increases in risk-adjusted payments from both chart reviews and HRAs.
Copyright:
The National Library of Medicine believes this item to be in the public domain. (More information)
Extent:
1 online resource (1 PDF file (28 pages))
Illustrations:
Illustrations
NLM Unique ID:
9918383787506676 (See catalog record)
Permanent Link:
http://resource.nlm.nih.gov/9918383787506676