Medicare Advantage plans are using chart reviews and health risk assessments to drive higher payments, to the tune of $9.2 billion, according to a new report from the Department of Health and Human Services' Office of Inspector General (OIG).
OIG analyzed MA encounter data from 2016 to determine whether plans were using chart reviews and HRAs to increase their risk-adjustment payments disproportionately relative to their size or their peers.
Chart reviews can identify diagnoses that were submitted in error, and HRAs can be used to gather additional information about beneficiaries to identify gaps in care.
According to the OIG report, 20 of the 162 MA insurers included in the study drove the bulk of the $9.2 billion in overpayments. Each generated a share of payments using chart reviews and HRAs that were 25% higher than their share of MA beneficiaries.
"We undertook this evaluation because of concerns that companies with contracts under Medicare Advantage may leverage both chart reviews and health risk assessments to maximize risk-adjusted payments, without beneficiaries receiving care for those diagnoses," OIG wrote in the report. "Unsupported risk-adjusted payments have been a major driver of improper payments in the MA program."
One insurer, which was not named, brought in 40% of risk-adjusted payments through these mechanisms, despite accounting for just 22% of MA beneficiaries.
This company accounted for one-third of payments from diagnoses based on chart reviews and more than half of payments from diagnoses based on HRAs, according to the report. In addition, many of the HRAs were conducted in the home by outside vendors, which could lead to lower-quality care coordination for beneficiaries, OIG said.
OIG recommended that the Centers for Medicare & Medicaid Services (CMS) provide additional oversight of the 20 insurers that accounted for much of the overpayments and that it should investigate further into the one company that substantially drove this behavior.
OIG also said CMS should perform periodic monitoring to identity MA insurers who may be bringing in high volumes of payments on the back of chart reviews and HRAs.
CMS was neutral on the recommendations and said it would take them into consideration in future policymaking.
OIG has been taking a close look at the MA program of late, including audits into major payers such as Aetna and Anthem.