Watchdog Flags $7.5 Billion Paid to Private Medicare Plans (1)

A government watchdog office is calling for greater oversight of private Medicare Advantage plans that received the majority of $7.5 billion in enhanced payments in 2023 that were based on potentially suspect patient diagnoses.

Most of these risk-adjusted payments were generated through in-home “health risk assessments” and HRA-linked chart reviews, according to the report by the HHS Office of Inspector General. These health risk assessments typically involve someone, who’s usually uninvolved in the patients’ care, visiting the beneficiaries’ homes and evaluating their medical conditions.

About half of Medicare beneficiaries get their coverage through Medicare Advantage plans, in which private insurance companies receive a set payment to cover each enrollee’s projected cost of care. The plans receive higher “risk-adjusted” payments for sicker beneficiaries with more projected medical costs.

The report found that UnitedHealth Group Inc. received more than $3.7 billion in estimated risk-adjusted payments from health risk assessments and chart reviews in 2023. Humana Inc. received nearly $1.71 billion, followed by Cigna Group, which received nearly $237 million.

The report found 20 Medicare Advantage 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.”

“The lack of any other follow-up 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,” the report said.

‘Misleading’ and ‘Incomplete’

UnitedHealthcare said in a statement that the report offered a “misleading, narrow and incomplete view of risk adjustment data” that “is being used to draw inaccurate conclusions about the value of in-home care for America’s most vulnerable seniors.”

“The 45–60 minute in-home visits provided by highly trained and board-certified advanced practice clinicians are among the most comprehensive and thorough assessments of a patient’s health and physical environment available in the healthcare system,” UnitedHealthcare said. “And the vast majority of these visits do not result in increased risk adjustment payments to MA plans.”

The CMS frequently audits the diagnoses submitted from home visits, UHC added, “and we consistently perform well in these audits.”

The in-home assessments help ensure better care and patient outcomes, Kevin Smith, a Humana spokesman, said in a statement.

“These assessments complement and support the care provided by primary care physicians and patients are always referred back to their physicians for follow-up care,” Smith said.

The OIG, the Centers for Medicare & Medicaid Services, and the Medicare Payment Advisory Commission have previously expressed concerns about Medicare Advantage plans using in-home assessments to boost their payments.

Restrictions Recommended

Based on the new report, the OIG recommended the CMS “impose additional restrictions on the use of diagnoses reported only on in-home HRAs or chart reviews that are linked to in-home HRAs for risk-adjusted payments.”

In a response letter, the CMS opposed this recommendation because OIG hasn’t “conducted medical record reviews of the diagnoses that came from visits that may have contained an HRA and have not concluded that these diagnoses are not accurate.”

The OIG also recommended that the agency conduct audits “to validate diagnoses reported only on in-home HRAs and HRA-linked chart reviews.”

The CMS again disagreed with the recommendation, saying the agency audits already “flag medical records that include HRAs during the medical record review process.” Using these assessments and other analyses, “CMS will then determine if a representative or targeted sample of diagnoses derived from in-home HRAs, and HRA-linked chart reviews is appropriate” for future audits.

The CMS concurred with an OIG recommendation to “determine whether select health conditions that drove payments from in-home HRAs and HRA-linked chart reviews may be more susceptible to misuse among MA companies.”