Watchdog Meets Strong Medicare Advantage Home Visit – KFF Health News
A new federal audit is increasing pressure on state officials to lower billions of dollars in premiums associated with Medicare Advantage plans.
But so far, the Centers for Medicare & Medicaid Services has rejected a proposal from the Health and Human Services Inspector General to reduce payments resulting from home visits that do not result in any medical treatment — a potential red flag. shows that there are many charges.
At the end of October, the HHS regulator found that health plans will spend $7.5 billion in 2023 from non-medical health screenings — about $4.2 billion of that through health screenings. beauty made in patients’ homes. And court records show that for a decade or more, CMS officials have failed to act on their concerns that families are draining tax dollars and should be cut.
UnitedHealthcare, the largest Medicare Advantage plan, accounts for about two-thirds of the payments related to home visits and chart reviews, where health plans dig through medical files. of patients to add new infections that could bring in more money, according to the analysis.
Deputy Auditor General Erin Bliss said health plans make billions without providing treatment for medical conditions they diagnose during travel, such as diabetes and major depression.
“Honestly, it has to stop,” Bliss said.
CMS, which administers the Medicare program, disagrees.
In a statement to KFF Health News through spokesperson Alexx Pons, the agency said it “appreciates the OIG’s review in this area” and will continue to study the matter.
However, CMS did not agree with the OIG’s request to restrict the use of home health assessments in calculating how much to pay for health plans. People on Medicare “should receive care that is provided appropriately in the home setting,” CMS wrote in a written response included in the audit report.
“One would think that CMS would take its regulatory controls down a notch or two,” said Richard Lieberman, a Colorado health data analyst.
“CMS, on the other hand, seems apathetic and is telling the OIG to get out of their way,” he said.
UnitedHealthcare spokeswoman Heather Soule said in a statement that the OIG reached “incorrect conclusions” in the review.
The home visit is “one of the most comprehensive and comprehensive assessments of the patient’s health and physical environment available in the health care system, to help identify and direct the care needed for the majority of those patients let’s meet them,” according to the company.
No Care Provided
Government spending on Medicare Advantage, which is managed by UnitedHealthcare and a handful of other health insurance companies, is expected to hit $462 billion this year.
The industry, whose more than 33 million members make up half of Medicare’s eligible population, argues that many enrollees are satisfied with the care they receive and typically pay less. than original Medicare.
Whether Medicare Advantage is a good investment for taxpayers is another matter, especially since many health plans are overstating how much sicker patients have to increase their copayments, several federal studies have found. and other research has shown. Medicare pays health plans higher rates for sick patients.
For fiscal year 2023, CMS has earmarked $12.7 billion in overpayments related to tests not supported by patients’ medical records.
The OIG audit linked $7.5 billion in payments to untreated health conditions, including serious illnesses such as diabetes, heart failure, and major depression. That suggests the medical condition was not present or that the health plan failed to adequately treat it, auditors said.
“These are serious situations. You would think you would see more attention that year,” said Jacqualine Reid, who led the OIG’s investigative team. “We’re asking CMS to increase its enforcement.”
Domestic
Indoor travel has been controversial for more than a decade. A June 2014 media investigation found that the dramatic rise in home visits had increased Medicare costs by billions of dollars. These visits, which usually last less than an hour, are usually made by nurses, who do not treat the patient, but look at a list of possible health conditions.
Sabrina Skeldon, a Texas attorney who advises doctors on payment issues, says problems arise when health plans fail to order the medical tests needed to confirm a diagnosis made during a visit — and it heals.
Skeldon noted that Cigna Group in 2023 paid $172 million to settle a whistle-blowing lawsuit that alleged its Medicare Advantage plan collected illegal payments for medical tests that were based on tests. domestic only.
The OIG review comes as the Justice Department presses a federal fraud case accusing UnitedHealth Group of defrauding Medicare out of more than $2 billion by mining patient records to produce tests that inflated the money, when they weren’t. they still ignore evidence of overpayment. The company denies the allegations.
Court filings from the case show CMS officials were concerned years ago that home visits and chart reviews could drive up costs unnecessarily.
In April 2014, CMS supported a proposal to ban their use amid complaints from the industry that it would lose billions of dollars as a result. Similarly, CMS officials dropped a proposal to enforce chart review after what one official called “uproar” from the industry.
CMS officials were also concerned that unaudited home visits could affect efforts to recover overpayments through rate reviews known as “RADVs.”
Former CMS official Thomas Hutchinson, who ran the Medicare Plan Payment Team from September 2006 to June 2010, testified that officials “heard from different people who saw how How can they do RADV proof stuff by visiting homes.”
In an April 2015 confidential hearing, CMS officials noted that health plans “currently conduct health risk assessments in beneficiary households. Another purpose of the tests is to identify conditions and create medical records that confirm the disease. ”
And an October 2015 CMS memo circulated among senior agency staff cites “weaknesses in home visiting” among possible ways to “strengthen” RADV findings.
In its statement to KFF Health News, CMS said it is “committed” to ensuring that health plans submitted for payment are valid. But the agency declined to answer written questions about the impact of home visits on its audit program, which has not completed audits of past payments since 2011.
UnitedHealthcare had the lowest unverified audit rates among the five largest Medicare Advantage organizations audited in 2011, according to court records.
In total, the company ended up underpaying $261 million for its 15 audited projects for 2011-2013, court records show. Audit findings for other Medicare Advantage firms have been dismissed in court documents.
CMS reviews 30 payments from more than 700 contracts per year. That’s not enough to protect tax dollars, said Matthew Fiedler, a health policy researcher at The Brookings Institution.
He said: “They should review the contracts 10 times.” “Where we are it’s not easy to get caught.”
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