For skilled nursing facilities, MA insurers under scrutiny for inflated risk scores may face payment clawbacks or stricter CMS audits that compress plan margins — and in turn, reimbursement rates to providers. Facilities contracting with the top 20 MA plans implicated in this report should monitor how any enforcement actions affect plan stability and coverage adequacy for high-acuity residents.
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.
— Office of Inspector General, October 24, 2024
United States, Department of Health and Human Services, Office of Inspector General. “Medicare Advantage: Questionable Use of Health Risk Assessments Continues To Drive Up Payments to Plans by Billions.” Office of Inspector General, 21 Oct. 2024. https://oig.hhs.gov/reports/all/2024/medicare-advantage-questionable-use-of-health-risk-assessments-continues-to-drive-up-payments-to-plans-by-billions/.
UnitedHealth collected billions in questionable Medicare payments, federal watchdog finds
A federal watchdog found that Medicare Advantage insurers led by UnitedHealth Group collected billions of dollars in dubious payments from Medicare by using home visits and medical chart reviews to diagnose patients with conditions for which they received no follow-up care. Insurers collectively received an estimated $7.5 billion in payments last year from health risk assessments (HRAs) and related reviews of medical records performed in 2022, a report released Thursday by the Office of Inspector General found.
— STAT, October 24, 2024
Medicare Advantage plans made $7.5B from ‘questionable’ assessments in 2023: OIG
Medicare Advantage companies are bringing in billions in “questionable” payments found during in-home visits and chart-reviews, HHS’ Office of Inspector General claimed in a new audit. In a report published Oct. 24, the federal watchdog estimated Medicare Advantage companies received $7.5 billion in payments through health risk assessments and chart reviews. The watchdog wrote that “questionable use” of HRAs is driving up payments to plans.
— Becker’s Payer, October 24, 2024
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