Compliance Today (November 2020)
The U.S. Department of Health & Human Services Office of Inspector General (OIG) September 2020 report titled Billions in Estimated Medicare Advantage Payments From Diagnoses Reported Only on Health Risk Assessments Raise Concerns[1] found that Medicare Advantage organizations (MAOs) received an estimated $2.6 billion in risk-adjusted payments for 2017 from diagnoses reported only on health risk assessments (HRAs)—and on no other service records.
These payments are being questioned. MAOs receive higher risk-adjusted payments based on diagnoses for Medicare beneficiaries expected to have greater healthcare needs.
According to the report, some MAOs “may be initiating and using HRAs [often by hiring companies to conduct HRAs in beneficiaries’ homes] to collect diagnoses and thereby maximize risk-adjusted payments without improving beneficiary care.” The OIG undertook this study due to concerns that “MAOs may use HRAs to increase risk-adjusted payments inappropriately.”
From its analysis of 2016 MA encounter data, the report authors found that:
-
“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.
-
“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.
-
“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.”
The findings raise concerns over (1) data integrity—that perhaps MAOs are “not submitting all service records as required”; (2) coordination of care—that the follow-up care to beneficiaries based on the HRAs diagnosis is not being received; and (3) “payment integrity concern, that if diagnoses are inaccurate or unsupported, the associated risk-adjusted payments would then be inappropriate.”
The OIG recommends the Centers for Medicare & Medicaid Services (CMS):
-
“Require MAOs to implement best practices to ensure care coordination for HRAs”;
-
“Provide targeted oversight of the 10 parent organizations that drove most of the risk-adjusted payments resulting from in-home HRAs”;
-
“Provide targeted oversight of the 20 MAOs that drove risk-adjusted payments resulting from in-home HRAs for beneficiaries who had no other service records in the encounter data”;
-
“Reassess the risks and benefits of allowing in-home HRAs to be used as sources of diagnoses for risk adjustment”; and
-
“Require MAOs to flag any MAO-initiated HRAs in their MA encounter data.”
CMS concurred with the second and third recommendations offered by the OIG. CMS Administrator Seema Verma noted in her comments that “in 2017, MAOs received approximately $200 billion in risk-adjusted payments. Therefore, the $2.6 billion OIG cites represents only 1 percent of all risk-adjusted payments. The vast majority of risk-adjusted payments distributed to MAOs are not a result of diagnoses reported only on HRAs.”
1 Christi A. Grimm, Billions in Estimated Medicare Advantage Payments From Diagnoses Reported Only on Health Risk Assessments Raise Concerns, U.S. Department of Health & Human Services, Office of Inspector General, September 2020, https://bit.ly/33uUGvn.
[View source.]
