“Medicare Advantage: Questionable Use of Health Risk Assessments Continues to Drive Up Payments to Plans by Billions,” Workplace of Inspector Basic | Authorities Oversight | U.S. Division of Well being and Human Companies
Why OIG Did This Evaluate
Medicare Benefit (MA) firms obtain larger risk-adjusted funds from CMS for enrollees who’re sicker, which helps to make sure that plans obtain adequate fee to cowl extra pricey care and enrollees have continued entry to MA plans. Nevertheless, taxpayers fund billions of {dollars} in overpayments to MA firms annually based mostly on unsupported diagnoses for MA enrollees. Unsupported diagnoses inflate risk-adjusted funds and drive improper funds within the MA program.
Utilizing 2016 MA encounter information, prior OIG work recognized two sources of enrollee diagnoses. The primary being well being danger assessments (HRAs), The second being chart evaluations as weak to misuse by MA firms. This analysis updates that work and determines whether or not vulnerabilities persist concerning the appropriateness of ensuing risk-adjusted funds and the standard of take care of enrollees with diagnoses reported solely on HRAs and on no different information of providers (i.e., service information) within the 2022 MA encounter information. This analysis additionally newly examines the extent to which MA firms use chart evaluations of knowledge gathered as a part of HRAs so as to add diagnoses that enhance their risk-adjusted fee (HRA-linked chart evaluations).
What OIG Discovered
Diagnoses reported solely on enrollees’ HRAs and HRA-linked chart evaluations, and never on some other 2022 service information, resulted in an estimated $7.5 billion in MA risk-adjusted funds for 2023. The dearth of some other follow-up visits, procedures, checks, or provides for these diagnoses within the MA encounter information for 1.7 million MA enrollees raises considerations that both: (1) the diagnoses are inaccurate and thus the funds are improper or (2) enrollees didn’t obtain wanted take care of critical circumstances reported solely on HRAs or HRA-linked chart evaluations.
In-home HRAs and HRA-linked chart evaluations generated virtually two-thirds of the estimated $7.5 billion in risk-adjusted funds. In-home HRAs and HRA-linked chart evaluations could also be extra weak to misuse as a result of these instruments are sometimes administered by MA firms or their third-party distributors and never enrollees’ personal suppliers. Diagnoses reported solely on these kinds of information heighten considerations in regards to the validity of the diagnoses or the coordination of take care of MA enrollees.
Simply 20 MA firms drove 80 p.c of the estimated $7.5 billion in funds. Additionally, these MA firms generated a considerably larger share of funds ensuing from HRAs or HRA-linked chart evaluations for sure well being circumstances, together with critical and continual diseases, equivalent to diabetes and congestive coronary heart failure.
What OIG Recommends
Along with implementing prior OIG suggestions, CMS ought to:
(1) impose extra restrictions on using diagnoses reported solely on in-home HRAs or chart evaluations which might be linked to in-home HRAs for risk-adjusted funds,
(2) conduct audits to validate diagnoses reported solely on in-home HRAs and HRA-linked chart evaluations, and
(3) decide whether or not choose well being circumstances that drove funds from in-home HRAs and HRA-linked chart evaluations could also be extra prone to misuse amongst MA firms. CMS concurred with our third suggestion however not the opposite two.
A short on a for much longer report is linked beneath. The over costs usually are not one thing new. Kip Sullivan. Merrill Goozner and others have reported on the identical and related abuse.
“Medicare Advantage: Questionable Use of Health Risk Assessments Continues To Drive Up Payments to Plans by Billions,” OEI-03-23-00380
