Becker's Hospital Review

22 CFO / FINANCE OIG: Medicare Advantage plans may be using health risk assessments to inflate payment By Morgan Haefner M edicare Advantage organizations may be improp- erly using health risk assessments to increase risk-adjusted reimbursement, according to a re- port HHS' Office of Inspector General issued in September. Risk-adjusted payments aim to level the financial playing field for Medicare Advantage plans that may enroll benefi- ciaries that require a costlier level of care than their peers. However, unsupported risk-adjusted payments could be a major driver of improper payments in the Medicare Advan- tage program, according to the OIG. In its analysis of 2016 Medicare Advantage encounter data, or records that show patient diagnoses and the services they received, the OIG found that in 2017, the government paid Medicare Advantage organizations about $2.6 billion in risk-adjusted payments that were only based on health risk assessment data and not encounter data. For 80 percent of these payments, Medicare Advantage orga- nizations used in-house risk assessment data. Most in-house assessments were conducted by companies that partner with or are hired by the Medicare Advantage organizations and "not likely conducted by the beneficiary's own primary care provider," according to the OIG. "Twenty [Medicare Advantage organizations] generated mil- lions in payments from in-home [health risk assessments] for beneficiaries for whom there was not a single record of any other service being provided in 2016," the OIG said. is raises three concerns, according to the OIG: • Medicare Advantage organizations may not be submit- ting all required service records. • Beneficiaries may not be getting follow-up care to ad- dress diagnoses identified during health risk assess- ments. • Associated risk-adjusted payments may be inappropri- ate because diagnoses are inaccurate or not supported. e OIG recommended that CMS increase its oversight of risk-adjusted payments. is is the second report in a 30-day period in which OIG has highlighted potential issues among Medicare Advantage organizations. In August, the OIG said CMS' encounter data continues to lack identifiers for ordering providers, which are used to identify potential fraud and abuse. n CMS scraps Medicaid fiscal responsibility rule By Alia Paavola C MS has withdrawn its proposed Medicaid Fiscal Ac- countability Rule, Administrator Seema Verma tweeted Sept. 14. CMS issued the proposed Medicaid Fiscal Accountability Rule last November. The rule aimed to promote transparency and fiscal integrity by establishing more reporting requirements for state supplemental payments to Medicaid providers. In mid-August, some hospital associations called on CMS to withdraw the rule, arguing that it could exacerbate the chal- lenges hospitals are facing in the U.S. The hospital associations, including America's Essential Hospi- tals and the American Health Care Association, argued that fi- nalizing the Medicaid fiscal integrity rule would introduce "un- precedented restrictions on states' ability to fund their share of the Medicaid program" at a time when hospitals are facing chal- lenges and an uncertain future due to the COVID-19 pandemic. "We've listened closely to concerns that have been raised by our state and provider partners about potential unintended consequences of the proposed rule, which require further study. Therefore, CMS is withdrawing the rule from the regula- tory agenda," Ms. Verma tweeted. n Drug costs surging faster than any other medical good or service, says GoodRx By Katie Adams W hile prices for most medical goods and services are rising, drug prices are increasing the fastest, accord- ing to a Sept. 17 GoodRx report. Researchers compared data on the prices of medical goods and services from the Bureau of Labor Statistics' Consumer Price Index to data on drug list prices from the GoodRx Drug List Price Index to find prescription drug prices have increased by 33 percent since 2014, the largest surge among all price increases for medical goods and services. Other medical ser- vices, such as care provided in inpatient hospital settings, nurs- ing homes and dental practices, increased by 30 percent, 23 percent and 19 percent, respectively. GoodRx's findings on prescription cost surges comes along- side findings that 25 percent of American women have forgone their medications and 10 percent of Americans have rationed their medications due to unaffordability. n

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