SHELBY LIVINGSTON December 12, 2019
HHS'
Office of Inspector General has raised new concerns about Medicare Advantage
insurers' use of medical chart reviews to obtain higher payments from the
federal government.
An
analysis of 2016 Medicare Advantage data found that insurers who reported
additional diagnoses after combing patients' medical charts were able to
increase their payments from the CMS by an estimated $6.7 billion in 2017,
according to the OIG's report published Thursday.
Though it
is a requirement, these diagnoses reported from the medical chart reviews,
which included serious illnesses like cancer, diabetes and heart disease, were
not supported by records of a patient's face-of-face visit with a clinician.
While
health insurers have insisted that they review patients' charts to ensure
accurate Medicare Advantage payments, the analysis showed they only rarely
submitted chart reviews that deleted incorrect diagnoses. Chart reviews that
resulted in deleted diagnoses decreased payments by just $196.5 million.
"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."
A
spokeswoman for America's Health Insurance Plans, the insurance industry's
lobbying organization, said the OIG's report is based on a type of data with
well-documented challenges, and noted that the OIG didn't review medical
records for the analysis. AHIP has long argued that "encounter data" is often incomplete or
inaccurate and would reduce insurers' payments.
The CMS
also called into question the OIG's estimated dollar amount of risk-adjustment
payments based on only chart reviews. The agency said the amount may be
inaccurate because the OIG's analysis focused only on encounter data and not
another type of data that is also used to calculate payments.
The way
the federal government calculates payments to Medicare Advantage plans gives
insurers an incentive to make their plan members appear as sick as
possible on paper. That incentive doesn't exist in the original Medicare
program.
Advantage
organizations are paid a per member, per month amount to provide care. In a
process known as risk-adjustment, payments are altered to pay more for sicker
seniors that are expected to incur higher medical costs, based on the patients'
demographic information and medical diagnoses submitted to the CMS by the
Advantage insurer. Diagnoses are required to be backed up by the patient's
medical record and documented from a face-to-face visit with a clinician.
Because
sicker members net higher payments, insurers often hire third-party vendors to
pore over patients' medical charts to find diagnoses that clinicians failed to
report to the insurer or reported in error. The OIG report showed that insurers
conducted a staggering amount of chart reviews in 2016: A total 553 Medicare
Advantage organizations submitted 52.6 million chart reviews for
risk-adjustment purposes.
The CMS
allows chart reviews to be submitted as encounter data, which is information
about patients documented by doctors and hospitals and is increasingly used by
the CMS to determine Advantage payments. Encounter data is blended with Risk
Adjustment Processing System data to calculate payments and is loathed by
insurers, though the Medicare Payment Advisory Commission supports its use.
The OIG's
findings add to other evidence that Medicare Advantage insurers may find ways
to exaggerate their patients' illnesses to obtain higher payments. The OIG has previously audited Advantage plans and found
that they were overpaid by hundreds of millions of dollars because of risk
scores that weren't supported by medical diagnoses. Moreover, the U.S.
Department of Justice has intervened in whistleblower lawsuits alleging that
UnitedHealth Group used chart reviews to exaggerate its plan members'
conditions to obtain higher payments.
According
to the OIG's new report, insurers submitted 40.6 million chart reviews adding
diagnoses, and for 41% of those reviews, there were no records of a patient
visit, procedure, test or supplies that contained those diagnoses.
"This
means that, for the entire year, these beneficiaries may not have received any
other services for the medical conditions indicated by the diagnoses," the
OIG wrote.
It also
found that 10 Medicare Advantage parent companies that enroll 70% of Advantage
members drove 79% of the risk-adjusted payments from chart reviews. Advantage
insurers received payments based solely on chart reviews for 1.7 million
patients. In one extreme case, a patient had diagnoses reported only on chart
reviews that resulted in about $229,050 in risk-adjusted payments to the
insurer.
Insurers
can link a chart review to a specific service associated with the diagnosis,
but the CMS does not require this, according to the OIG report. The OIG
estimated that the CMS based $2.7 billion in payments on chart review diagnoses
that the insurers did not link to any service provided to the beneficiary in
2016.
"For
beneficiaries with unlinked chart reviews, and no records of services in all of
2016, it is not at all clear what services were used to generate diagnoses
added on these chart reviews," it wrote.
The OIG
recommended that the CMS provide more oversight of insurers that received
payments from unlinked chart reviews and conduct audits to validate the
diagnoses reported on chart reviews. It also advised the CMS to reassess the
risks and benefits associated with allowing unlinked chart reviews to be used
for risk adjustment. The agency agreed with the recommendations.
No comments:
Post a Comment