OIG: MA companies used chart reviews, health risk assessments to boost CMS payments

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Some insurers providing Medicare Advantage plans used chart reviews and health risk assessments to drive up federal payments to the tune of billions of dollars, according to a study by the Department of Health and Human Services’ Office of Inspector General.

Of the 162 MA companies included in the analysis, 20 generated a disproportionate share of the $9.2 billion in total payments from diagnoses that were reported only on chart reviews and health risk assessments in 2016. The diagnoses were not reported on any other service records.

Chart reviews and health risk assessments are permitted as sources of diagnoses for risk adjustments, that is, the process by which the Centers for Medicare and Medicaid Services determines payments for MA beneficiaries expected to have higher-than-average medical costs.

“The risk adjustment program is an important payment mechanism for MA,” the agency said in a summary of the study posted to its website. “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.”

A chart review is an examination of a beneficiary’s medical record conducted by the payer to identify diagnoses that a provider either did not submit or submitted incorrectly. A health risk assessment is conducted to diagnose a beneficiary and identify possible gaps in care. A healthcare worker collects information from a beneficiary about their health status, health risks and daily activities.

But there are concerns that MA companies may use these processes to maximize risk-adjusted payments without beneficiaries receiving care for those diagnoses.

For the 162 MA companies studied, OIG researchers collected chart reviews and health risk assessments included in MA encounter data for 2016. They also gathered CMS data on the number of beneficiaries enrolled in each MA company as of Jan. 1, 2016.

As mentioned above, the MA companies generated an estimated $9.2 billion in risk-adjusted payments from diagnoses that were reported only on chart reviews and health risk assessments.

The top 20 companies generated $5 billion in payments. Just 12 health conditions accounted for two-thirds of these payments, with vascular disease and major depressive, bipolar and paranoid disorders topping the list.

Each company generated a share of the payments that were more than 25% higher than their share of MA enrollees. The top 20 companies enrolled only 31% of MA beneficiaries but generated 54% of the $9.2 billion in payments.

Further, among the top 20, there was one company that generated 40% of the risk-adjusted payments from both mechanisms and yet enrolled only 22% of MA beneficiaries.

The OIG urged CMS to more closely oversee the 20 MA companies that had a disproportionate share of the risk-adjusted payments and perform periodic monitoring to keep this issue in check.

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