These practices were concentrated among a small number of MA payers, particularly concerning given the involvement of in-home HRAs. The OIG recommends that CMS impose stricter controls on HRA-based diagnoses and conduct audits to validate their accuracy.
Medicare Advantage (MA) companies receive higher risk-adjusted payments from the Centers for Medicare & Medicaid Services (CMS) for enrollees who are sicker, which helps to ensure that plans receive sufficient payment to cover more costly care and enrollees have continued access to MA plans. However, taxpayers fund billions of dollars in overpayments to MA companies each year based on unsupported diagnoses for MA enrollees. Unsupported diagnoses inflate risk-adjusted payments and drive improper payments in the MA program.
Diagnoses reported only on enrollees’ HRAs and HRA-linked chart reviews, and not on any other 2022 service records, resulted in an estimated $7.5 billion in MA risk-adjusted payments for 2023. The lack of any other followup visits, procedures, tests, or supplies for these diagnoses in the MA encounter data for 1.7 million MA enrollees raises concerns that either: (1) the diagnoses are inaccurate and thus the payments are improper or (2) enrollees did not receive needed care for serious conditions reported only on HRAs or HRA-linked chart reviews.
In-home HRAs and HRA-linked chart reviews generated almost two-thirds of the estimated $7.5 billion in risk-adjusted payments. In-home HRAs and HRA-linked chart reviews may be more vulnerable to misuse because these tools are often administered by MA companies or their third-party vendors and not enrollees’ own providers. Diagnoses reported only on these types of records heighten concerns about the validity of the diagnoses or the coordination of care for MA enrollees
Just 20 MA companies drove 80 percent of the estimated $7.5 billion in payments. Also, these MA companies generated a substantially greater share of payments resulting from HRAs or HRA-linked chart reviews for certain health conditions, including serious and chronic illnesses, such as diabetes and congestive heart failure.
Medicare advantage: Questionable use of health risk assessments continues to drive up payments to plans by billions. (2024, October 25). Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services. https://oig.hhs.gov/reports/all/2024/medicare-advantage-questionable-use-of-health-risk-assessments-continues-to-drive-up-payments-to-plans-by-billions/
Rowan, T. (2024, November 8). Here we go again. The Rowan Report. https://www.therowanreport.com/2024/11/08/padding-patient-assessments-again/
Ross, C., Bannow, T., Lawrence, L., & Herman, B. (2024, October 25). UnitedHealth collected billions in questionable Medicare payments, federal watchdog finds. STAT. https://www.statnews.com/2024/10/24/hhs-oig-report-hra-chart-review-medicare-advantage-payments-unitedhealth-humana/
OIG report finds insurers collected billions in questionable MA payments | AHA News. (2024, October 24). American Hospital Association | AHA News. https://www.aha.org/news/headline/2024-10-24-oig-report-finds-insurers-collected-billions-questionable-ma-payments
Wilson, R. (n.d.). Medicare Advantage plans made $7.5B from “questionable” assessments in 2023: OIG. https://www.beckerspayer.com/policy-updates/medicare-advantage-plans-made-7-5b-from-questionable-assessments-in-2023-oig.html
Improve Medicare Advantage reimbursements with payer contract management that puts payer rules in the hands of clinicians & billers.
