Category: MM Curator

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MCOS/PHE- The Role of Medicaid Managed Care Organizations in the PHE Unwinding

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A new survey of plans shows that most don’t have the up to date data CMS and states are hoping they have to help with the Return to Normal Operations.

 
 

 
 

Clipped from: https://healthpayerintelligence.com/news/the-role-of-medicaid-managed-care-organizations-in-the-phe-unwinding

Medicaid managed care organizations can help mitigate the negative effects of the public health unwinding in a variety of ways.

Source: Getty Images

 
 

By Kelsey Waddill

February 14, 2023 – Medicaid managed care organizations have a key role to play in the public health unwinding, a Kaiser Family Foundation (KFF) brief found.

The brief’s findings are based on two study components: a survey of Medicaid managed care organizations fielded from October to November 2022 and a roundtable discussion in November 2022. Out of 65 Association for Community Affiliated Plans (ACAP) plans, 29 plans in 15 out of 26 states contributed to the survey and ten plans participated in the roundtable.

Medicaid managed care organizations will have to update beneficiary contact information, conduct outreach, support coverage transitions, and navigate the effects of the unwinding.

Only 31 percent of ACAP plan respondents said that they had verified or up-to-date contact information for 76 to 100 percent of their Medicaid beneficiaries and 28 percent said that 51 to 75 percent of their Medicaid beneficiaries’ contact information was verified or current.

Moreover, the data that plans do receive from their Medicaid agencies may not be accurate. Less than four out of ten of the respondents (38 percent) said the beneficiary contact data from Medicaid agencies was accurate most of the time. Another 45 percent reported that it was accurate half of the time or less and the remaining 17 percent did not know.

While most plans reported taking steps to connect with beneficiaries, health plans faced a few barriers to connecting with Medicaid beneficiaries and other challenges related to Medicaid beneficiary communication.

Almost all participating plans (90 percent) experienced challenges in reaching Medicaid beneficiaries. More than half of the respondents faced barriers to acquiring or updating beneficiary information due to state regulations or the Telephone Consumer Protection Act (TCPA). Four out of ten plans experienced challenges due to HIPAA and another 21 percent struggled working with third parties.

For most Medicaid managed care organization respondents, states planned to send a monthly file of the beneficiaries undergoing renewals and many will provide files on beneficiaries who have not yet submitted renewal forms and those who may lose their coverage.

Fifty-two percent of the survey respondents intended to target certain populations—such as individuals with chronic conditions, pregnant individuals, or those with substance use disorders—for renewal outreach.

“Plans indicated these targeted outreach strategies would include additional communication; customized messaging; call center and provider portal alerts for select members; leveraging care managers, transition teams, and life coaches; and partnering with CBOs to provide in-home application assistance for members with disabilities and homebound members,” the brief explained.

Over 50 percent of plans expected to receive termination files from their state’s Medicaid agency on a monthly basis. Managed care organizations that offer a qualified health plan on the Affordable Care Act marketplace can share qualified health plan information with disenrolled individuals, if their states allow such activities. Nearly all the respondents who could alert disenrolled beneficiaries to their qualified health plans intended to do so.

Health plans predicted significant coverage loss among their beneficiaries, with 75 percent of health plans expecting 10 to 25 percent of their enrollees to lose Medicaid coverage. These expectations align with separate predictions. A quarter of health plans expected that 10 to 25 percent of their beneficiaries would lose coverage due to procedural reasons.

“Responding plans most frequently reported decline in Medicaid enrollment and related revenue loss, enrollee churn, and disruptions in member care as significant challenges they are expecting related to unwinding,” the brief found.

These statistics reveal the influence that Medicaid managed care plans have over the impacts of the public health unwinding, including Medicaid redeterminations and renewals.

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STATE NEWS/ENROLLMENT- Mark Farrah Associates Assessed Medicaid Market Share in Texas

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A nice tidy look at the major MCO players in 3 Texas counties.

 
 

 
 

Clipped from: https://www.businesswire.com/news/home/20230215005712/en/Mark-Farrah-Associates-Assessed-Medicaid-Market-Share-in-Texas

MCMURRAY, Penn.–(BUSINESS WIRE)–Mark Farrah Associates (MFA) analyzed Medicaid enrollment figures from its County Health CoverageTM database product for three counties in Texas, with a focus on health plan market position. Prior to the COVID-19 Pandemic, Texas Medicaid enrollment was approximately 3.1 million (as of December 31, 2019). Since then, the program has expanded 75% to cover nearly 5.3 million Texans, as of September 30, 2022. MFA’s analysis covers the top three counties in Texas, based on Medicaid enrollment: Harris, Dallas, and Bexar.

  • As of 3Q22, over 35% of Texas’s Medicaid enrollment is in three counties: Harris, Dallas, and Bexar.
  • Harris County (Houston area) had the largest Medicaid enrollment in the state as of 3Q22, with Texas Children’s Health Plan providing coverage for over 42% of the county’s market.

 
 

  • Dallas County had the second largest Medicaid enrollment in the state as of 3Q22, with Elevance Health, Inc. (formerly Anthem) comprising 46% share of the market.
  • Bexar County, San Antonio area, is the third largest county in Texas for Medicaid enrollment, with Centene accounting for 46% of the county’s market as of 3Q22.
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PROVIDERS- Dental care rose among low-income pregnant women after 2015 Medicaid change

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: VA opened up dental services (beyond emergency extractions) for pregnant moms and has seen a 14% increase in utilization for dental services since 2015.

 
 

 
 

Clipped from: https://www.virginiamercury.com/2023/02/13/study-dental-care-rose-among-low-income-pregnant-women-after-2015-medicaid-change/

 
 

(Katie O’Connor / Virginia Mercury)

More pregnant women enrolled in Medicaid are getting dental care after a 2015 change in state regulations that expanded Virginia Medicaid coverage.

A new study from Virginia Commonwealth University’s School of Dentistry and Business found Medicaid-enrolled pregnant women who self-reported having dental insurance jumped from 44.4% to 71.6% between 2013-14 and 2016-19, the three-year period following the change, while those receiving dental services grew from 30.3% to 44.3%.

Prior to the 2015 change, emergency extractions were the only dental service coverage available for pregnant enrollees. 

Medicaid is “definitely a huge sigh of relief for people who need care,” said Shillpa Naavaal, lead author of the VCU study, especially for operations like root canals and crowns that can cost upward of $2,000 out of pocket.

However, researchers say many pregnant people enrolled in Medicaid still don’t know they have dental coverage and more work needs to be done to increase awareness.

A 2015 regulation issued by former Gov. Terry McAuliffe’s administration expanded Medicaid benefits to include comprehensive dental coverage for pregnant women aged 21 years and older through 60 days postpartum as part of the A Healthy Virginia Plan. 

Oral health problems during pregnancy are associated with serious health consequences for both mother and baby, the VCU study reports, including high blood pressure, premature birth and low birth weight. 

The purpose of the study, Naavaal said, was to understand when or how the change would impact pregnant Medicaid enrollees.

“The policy was put in place and things kind of moved on,” Naavaal said. “We really didn’t know what happened after.”

Nearly 35,000 pregnant Virginians are enrolled in Medicaid as of this month, according to the Virginia Department of Medical Assistance Services.

Researchers analyzed data from the Virginia Pregnancy Risk Assessment Monitoring System, a survey designed to capture women’s experiences during pregnancy in the years before and after Virginia’s policy change. 

While the increase in dental care is an encouraging sign, Naavaal said, the data indicate some pregnant women don’t realize they have dental benefits through Medicaid. 

There are many ways to increase awareness of the benefit, Naavaal said, such as media coverage and Medicaid itself directly informing enrollees and medical and dental providers.

Medicaid-enrolled pregnant women may not think about dental care during their pregnancy if they don’t know about the benefits, Naavaal said, but maternal care providers could inform them of the coverage and importance of using it. 

Additional barriers may also be preventing low-income women from getting dental services while pregnant. For example, it’s possible that some women in the study weren’t able to schedule time for an appointment within their window of eligibility or were unable to find a provider nearby who accepted Medicaid patients. 

Virginia lawmakers voted to expand Medicaid eligibility again in 2019 after years of Republican opposition by increasing the income threshold for eligibility to 138% of the federal poverty level, which is currently $18,754 for a single individual. 

In 2021, the state’s budget included dental care coverage for all new and current Medicaid enrollees ages 19 to 64, as well as coverage for pregnant women regardless of their immigration status. 

“Hopefully after five years we do the study again, we see that there are only a few that don’t know or that everybody now knows that they do have coverage,” said Naavaal.

Dental services for pregnant Medicaid enrollees are offered through the Smiles for Children program. Details can be found through the Virginia Department of Medical Assistance Services website. 

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MH/BH- Hundreds of thousands of Medicaid patients seek mental health care in emergency rooms

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A new study begins to quantify how much ED is used for mental health in multiple states.

 
 

 
 

Clipped from: https://oregoncapitalchronicle.com/2023/02/13/hundreds-of-thousands-of-medicaid-patients-seek-treatment-in-emergency-rooms/

A study by Oregon Health & Science University found that patients in Iowa, Nevada and Ohio had the highest rates of use, while Oregon was in the middle

 
 

Emergency rooms, like the one at Oregon Health & Science University, end up boarding mental health patients who have no where else to go. (Christine Torres Hicks/OHSU)

A new study shows that hundreds of thousands of low-income patients seek mental health care every year in emergency departments across the country rather than in clinics designed to treat them.

Those patients include thousands of Oregonians, the study’s lead author told the Capital Chronicle.

John McConnell, a health economist at Oregon Health & Science University, led the study, which he said was one of the first of its kind to use newly available Medicaid data to chart emergency department visits for mental illness. 

“Mental health is very important to the Medicaid program,” McConnell said. “Medicaid covers a disproportionate number of people with mental health conditions. It’s hard to really measure access to mental health care, so you can consider this a proxy for access to care.”

Published in the journal Health Affairs, the study looked at 12 million adults in 2018 on Medicaid, which covers one in four in Oregon and nearly as many nationwide. The researchers found that these patients in some states – Iowa, Nevada and Ohio – had the highest number of per-capita emergency department visits for mental health care, while patients in other states – Colorado, West Virginia and Arizona – sought emergency care for a mental health issues at the lowest rates nationwide.

Oregon fell in the middle.

McConnell said that probably reflects an emphasis in Oregon on keeping people on Medicaid out of emergency departments. Regionally based insurers, called coordinated care organizations, manage care for Oregon’s Medicaid patients. The state has pressured them to reduce the rate of ER visits for mental health care, especially among patients with severe and persistent conditions.

McConnell estimated that Medicaid patients in Oregon sought emergency mental health care up to 12,000 times in 2018.

“In a perfect world, we don’t want a lot of people to go to the ER to get their mental health care,” McConnell said. “It’s a place that takes all comers. It’s really designed for acute care. A lot of mental health treatment requires something more than an hour-long visit.”

Mental health treatment can take time and sometimes requires medication. Residential facilities and clinics are designed to treat these patients – and can do so successfully, experts say.

Although Oregon falls in the middle in the study, nationwide surveys have shown a high prevalence of mental illness in Oregon and a low access to treatment. This session, the Legislature is looking again at boosting funding to expand residential treatment capacity and attract more workers to the field.

The study did not analyze why the patients sought help in emergency departments rather than clinics or other facilities. But researchers said this is something for states to look at. 

“Do high rates of utilization for both ambulatory and emergency mental health care suggest a region under duress, or are they an indicator of high capacity and low quality? Or do they reflect idiosyncratic patient preference and provider coding practice?” the study asked.

Researchers found little correlation between visits for anxiety and schizophrenia or between visits for depression and suicide.

“These findings suggest that a ‘one-size-fits-all’ solution to improving mental health may be less effective than programs likely tailored to the local population’s needs,” the study said.

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FWA- Tennessee Medicaid pursues felony charges against some members

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Sometimes the effort to protect Medicaid resources from fraudsters gets the wrong people.

 
 

Clipped from: https://www.npr.org/sections/health-shots/2023/02/13/1156145443/tennessee-medicaid-mix-up-felony

 
 

Life was upended for LaShonia Ingram over the last year, and a shadow still follows her around.

Search her name online, and the first result includes the words “fraud” and “most wanted.”

“It was horrible. I couldn’t get a job,” says the 42-year-old mother from Memphis, Tennessee. “All doors were being closed in my face.”

Ingram resorted to selling purses out of her trunk to support her family. She says even DoorDash and Uber wouldn’t allow her to work with a felony charge.

Her alleged crime? Fraud.

The state of Tennessee accused her of living in nearby Horn Lake, Mississippi, while still being enrolled in the state’s Medicaid program, known as TennCare. It all turned out to be a mix-up, but the damage to her reputation and finances was done.

Tennessee is one of the most aggressive states in the nation when it comes to policing possible Medicaid fraud among beneficiaries like Ingram. The state posts the names and photos of people arrested for alleged fraud on a government website and social media. Some even wind up on a so-called “most wanted” list, as if they were dangerous and on the run.

The list is maintained by Tennessee’s Office of Inspector General. The office was launched in 2005 when most of the cases involved drug diversion: people were accused of using TennCare benefits to acquire massive quantities of narcotics to sell on the street. But as federal rules have slowed the illegal prescription drug market, arrests related to Medicaid are instead sweeping up people accused of moving out of state — often within the same community — without canceling their benefits.

An apparent clerical error leads to an arrest

Ingram was one of 28 Medicaid beneficiaries in Tennessee charged in 2022, according to the Tennessee OIG; more than a third of them were accused of not being a Tennessee resident, with many cases originating in the Memphis area where some of the suburbs are in Mississippi.

In Ingram’s case, Tennessee announced her arrest in a press release, saying she “eluded” authorities for nearly a year. Ingram says she didn’t have a clue about the charges until she got a ticket for not wearing her seatbelt.

“They pulled me over, and they said, ‘you have a felony warrant.’ And I said, ‘quit lying,'” she recalls. “I’ve never been in trouble a day in my life.”

It took $2,000 to bond out of jail and even more to hire an attorney. Not until more than six months later did prosecutors show her the evidence so she could refute the charges and clear her name.

The explanation ended up being pretty straightforward. During the time she was on Tennessee’s Medicaid program and living in Memphis, she filed for divorce from her husband who lived nearby in Mississippi. She says they had been separated for years, but her driver’s license still had the outdated Mississippi address.

After her arrest, Ingram showed her Tennessee lease and electric bills, and the Shelby County District Attorney dropped the felony charges.

Most states focus on health care provider fraud

Every state has an office to investigate Medicaid fraud committed by doctors and other health care providers, since that’s usually where the most money can be recovered. Not as many crack down on patients like Tennessee does.

“We try to apply the law compassionately,” Chad Holman, who leads the TennCare OIG, told NPR.

Some other states do have patient-focused units, but they don’t necessarily name the accused publicly. For example, South Carolina keeps them anonymous even after they’ve agreed to reimburse the state.

Holman defends Tennessee’s practice of posting a “most wanted” list for its Medicaid program. He says it’s supposed to be a deterrent: “It’s not to blast anyone or defame anyone. It’s to simply take care of the business that’s at hand, hold people accountable and do what we’re here to do,” he says.

As drug-related cases have diminished, enforcement has increasingly focused on ensuring that people enrolled in TennCare live in the state. In Memphis, 20 of the 27 Medicaid fraud cases since 2019 involved questions of state residency, according to the Shelby County District Attorney. And prosecutors have dropped at least a half dozen of those cases because the evidence was so weak.

Holman says his office won’t overlook low-level offenses.

“This is not murder,” he says. “But the legislature classified it as a felony, and that’s the law that I’m here to enforce.”

But enforcement is expensive. And Holman acknowledges it costs far more to run the TennCare fraud unit than the office will ever recoup from people on Medicaid, who are usually low-income to start with. Even if the state recovered every dollar from charges brought against beneficiaries in 2022, the total would amount to less than $900,000. The office has a budget of $6.4 million a year. Since its creation in 2005, the OIG has brought in less than $10 million and charged nearly 3,200 people with fraud, according to its own press releases.

And the rate of arrests has slowed dramatically. It now arrests fewer people in a year than it previously did in a single month.

A Medicaid ‘cliff’ is coming

At this point, about one in four Americans is on Medicaid or CHIP — the Children’s Health Insurance Program. The number of people enrolled increased by more than 20 million since early 2020. And for the first time since the start of the pandemic, states are going to be verifying income and addresses over the next year. Millions of Americans could lose their Medicaid coverage as a result. It’s up to each state to determine who is eligible and how to deal with potential fraud in the program.

Michele Johnson, executive director of the Tennessee Justice Center, says policing fraud among TennCare beneficiaries takes time and money that could be spent on something more helpful.

“It’d be great if our leaders would get out of the gotcha game and get into the getting people healthy game,” she says.

Especially now, as Medicaid programs are restarting checks on eligibility, Johnson says recipients shouldn’t have to worry that a mistake could eventually get them arrested.

Despite the ordeal she went through, Ingram is bouncing back. Still, she has legal bills to pay and has grown more frustrated at being ensnared by the state’s Medicaid dragnet.

“They made a big mistake,” she says.

This story was produced in partnership with Nashville Public Radio and Kaiser Health News.

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FWA- Former Las Vegas Medicaid provider sentenced to prison in fraud case

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: A home health provider stole $775k from Medicaid using a bogus claims scam.

 
 

Clipped from: https://news3lv.com/news/local/former-las-vegas-medicaid-provider-sentenced-to-prison-in-fraud-case

 
 

Home health agency

 
 

 
 

Las Vegas (KSNV) — A former Medicard provided has been sentenced following the investigation of a fraud case that began in 2017.

64-year-old Tonda Renee Ward of Las Vegas, along with her company Southwestern Health Solutions L.L.C., was sentenced on Wednesday, Nevada Attorney General Aaron D. Ford announced.

The fraud case claimed Ward and her company submitted false claims and failed to maintain adequate records between December 31, 2017, and December 26, 2018.

MORE ON NEWS 3 | Suspect in Brooklyn truck rampage was arrested for stabbing Las Vegas neighbor in 2020

Judge Mary Kay Holthus found the company guilty of one count of Submitting False Claims: Medicaid Fraud, a category D felony. The defendant was ordered to pay $775,000 in restitution, costs, and penalties.
 

Ward was also found guilty of Intentional Failure to Maintain Records and was sentenced to 364 days in the Clark County Detention Center, suspended; placed on probation; and ordered to pay an additional $25,000.

This case was investigated by the Attorney General’s Medicaid Fraud Control Unit and was prosecuted by Senior Deputy Attorney General Behnaz Salimian Molina.
 

Anyone who wishes to file a complaint with the Office of the Nevada Attorney General can do so here.

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FWA- The Pill Club reaches $18.3M settlement for alleged Medicaid fraud in California

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Was the name of the company really not a red flag?

 
 

 
 

Clipped from: https://www.mobihealthnews.com/news/pill-club-reaches-183m-settlement-alleged-medicaid-fraud-california

 
 

Photo: krisanapong detraphiphat/Getty Images

Online birth control pharmacy The Pill Club reached an $18.3 million settlement with California authorities for allegedly defrauding the state’s Medicaid program.

According to the California Department of Justice, the company billed Medi-Cal for services it hadn’t provided, allegedly submitting claims for 30-minute face-to-face counseling sessions when its nurse practitioners didn’t have direct or real-time contact with patients. The California Department of Insurance said the birth control provider would bill for in-person visits when nurses were only reviewing patient questionnaires.

The state DOJ also claimed The Pill Club dispensed female condoms to beneficiaries who didn’t want or ask for the contraceptives, billing Medi-Cal significantly above the retail price.

The settlement calls for $15 million to be paid to the DOJ, while $3.3 million will go to the CDI. It comes days after a state court unsealed a whistleblower complaint against The Pill Club, where former nurse practitioners also alleged the company had defrauded private insurers in at least 38 states, including California.

According to a statement from their attorneys, the whistleblowers will receive nearly $5 million from the settlement. 

“The Pill Club unacceptably siphoned off Medi-Cal funding intended to help vulnerable communities access essential healthcare,” California Attorney General Rob Bonta said in a statement. “I am grateful to the whistleblowers and our investigators who were instrumental in holding The Pill Club accountable.

“At the California Department of Justice, we fight every day to protect and expand access to healthcare. We will not tolerate companies who attempt to unlawfully enrich themselves at Medi-Cal’s expense.”

A spokesperson for The Pill Club said it wasn’t required to be monitored or change any business practices as part of the settlement, and they noted it wasn’t settling in any other states. However, the company plans to improve its billing practices, update measures to ensure patients only receive medications and contraceptives they request, and implement new patient informed consent practices.

“When I joined The Pill Club just over two years ago, I was drawn to the challenge of strengthening our operations to live up to our mission. I’m glad to have the opportunity to resolve these issues and to bring our full focus back to expanding access to contraceptive care for all who need it,” Liz Meyerdirk, The Pill Club’s CEO, said in a statement.

THE LARGER TREND

The Pill Club, which launched in 2016, raised a $51 million Series B three years later and another $41.9 million in 2021.

The company briefly changed its name to Favor to highlight its non-contraceptive services, but it returned to its previous branding following a lawsuit from a restaurant and retail delivery company that also used the name.

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FWA- NY OMIG Finalizes Omnibus Regs Impacting Medicaid Providers’ and Plans’ Compliance Obligations

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: NY MCOs will have to ramp up their internal efforts to fight FWA.

 
 

 
 

Clipped from: https://www.jdsupra.com/legalnews/ny-omig-finalizes-omnibus-regs-2406437/

 
 

On December 28, 2022, the New York State Office of the Medicaid Inspector General (OMIG) finalized the proposed rule published on July 13, 2022, that significantly revises the provider and Medicaid managed care organization (MMCO) compliance obligations in New York with no substantive changes. The new regulations became effective immediately upon issuance; however, OMIG enforcement will be delayed until March 28, 2023 (90 days after the effective date of the regulations).

As we previously reported, the rules incorporate some of OMIG’s guidance issued to providers on compliance program best practices and expectations. Additionally, the rules expand the requirement for MMCOs to have a Special Investigations Unit (SIU); build upon existing requirements related to MMCOs’ requirements governing plans’ fraud, waste and abuse prevention programs; and codify OMIG’s self-disclosure protocols for providers and MMCOs, with limited changes. In conjunction with the promulgation of these new compliance regulations, OMIG will be providing ongoing guidance and training in the form of statewide presentations, webinars and compliance program reviews. OMIG has published new compliance guidance materials on its website under the Compliance Library tab, including a document that compares the requirements in effect prior to these final regulations to the current requirements.

We strongly recommend that providers and MMCOs perform a compliance program effectiveness review utilizing these new standards, as OMIG intends to commence compliance program audits of providers to assess their compliance with these new standards. OMIG indicated in a recent presentation that a score of less than 60% compliance may result in enforcement actions, and even a “passing” score likely will result in corrective actions.

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MEDICARE/FWA-Public Health & Policy Reading Room | CMS Rule Means Medicare Advantage Plans Will Pay Back Billions in Overpayments

MM Curator summary

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: MA plans will have to pay back a lot of cash that they stole back when CMS let them get away with the rampant upcoding. The first year that CMS will enforce the paybacks will be 2018. Why that year? I wonder how much overpayments MA plans got the few years before that, and who was in charge at CMS those years, and did they have any specific connection to the overall RADV upcoding scandal? Probably just a bunch of dead end questions, I’m sure.

 
 

Clipped from: https://www.medpagetoday.com/reading-room/publichealthpolicy/medicare/102889

– Audits finding unsubstantiated claims will extrapolate overpayments to insurers’ other claims

With a more aggressive rule finalized Monday, the Centers for Medicare & Medicaid Services (CMS) said it expects to recover billions more in overpayments from Medicare Advantage plans that upcoded their enrolled beneficiaries as being sicker or requiring more intense levels of care than their medical records could support.

The agency’s revised risk adjustment data validation (RADV) tool will allow the agency to extrapolate the amounts of overpayments found in audited claims that must be repaid to much larger sets of claims submitted by the plan that year. It will “protect the fiscal sustainability” of Medicare, said Health and Human Services Secretary Xavier Becerra during a news conference.

The new extrapolation policy applies to plan years 2018 and later. CMS will not apply the policy to prior years, meaning Medicare Advantage plans will get to keep the money audits determined were wrongfully obtained.

Until now, the amount the plans were supposed to pay back was based just on those overpayments that audits found among the small sample of claims audited. But the new rule enables Medicare to extrapolate the amount owed from those audited claims to all claims submitted for patients in a diagnostic subgroup, thus putting companies on the hook to pay back a lot more money.

“Thanks to this final rule, CMS will now be able to provide appropriate oversight and ensure the integrity of the entire Medicare program by taking specific steps to collect payments made to Medicare Advantage plans to which they were never entitled under our laws and regulations,” Becerra said.

Dara Corrigan, director of the CMS Center for Program Integrity, estimated that in plan payment year 2018 alone, the agency expects to recover $479 million under the new rule. For the 10-year period of 2023 to 2032, it’s estimated the amount recovered will reach $4.7 billion.

The problem has evolved because Medicare Advantage organizations (MAOs) receive a lot more money from Medicare each month for patients with higher health risk scores, as sicker patients presumably will cost more money. But CMS audits have revealed enrollee health histories that do not substantiate their illness, along with patients never treated for their apparent conditions. “There is an incentive for MAOs to potentially over-code diagnoses to increase their payments, that is, to code diagnoses not properly substantiated by medical record documentation,” CMS said in its final rule.

Dozens of Office of Inspector General (OIG) investigations have found most of the largest Medicare Advantage plans have coded their enrollees with illnesses or conditions that the plan providers’ medical records could not support. In the last 2 years alone, OIG released results of investigations that found exaggerated upcoding worth $461 million, according to a MedPage Today search of the agency’s investigative findings.

The practice continues. In its final rule Monday, CMS said that in fiscal year 2021, based on 2019 payments, “we calculated that CMS made over $15 billion in Part C overpayments, a figure representing nearly 7 percent of total Part C payments.”

The agency had originally proposed beginning the extrapolation method for assessing overpayments that MAOs needed to pay back starting with the 2011 payment year.

Asked why the agency decided not to expand the new RADV rule to years before 2018, Corrigan said the agency had to consider all policy discussions and stakeholder input, and the integrity of the program.

The rule also explains that the 2018 year was selected as the starting point for the new policy because of the number of appeals expected from MAOs. “By not using an extrapolation methodology prior to [payment year] 2018, we expect to better control the total number of active appeals that are submitted in the first few years following finalization of this rule, which will alleviate burden on MAOs and CMS,” the rule explained.

Asked if MAOs will challenge the new rule with lawsuits, Becerra and Corrigan declined to comment. “We have a policy on not commenting on any future litigation,” said Corrigan.

In a press release accompanying the rollout of the final rule, CMS said that despite audit findings of overpayments to Medicare Advantage plans going back years, no risk adjustment overpayments have been collected since payment year 2007.

The rule explained that CMS will focus on overpayment subgroups identified by hierarchical condition categories (HCC), representing clinical diagnoses, that are at the highest risk for improper payments.

Better Medicare Alliance, a coalition of stakeholders including MAOs, said it is still reviewing the new rule. But the organization has concerns about “potential unintended consequence of creating an environment of higher premiums and fewer benefits for the more than 29 million seniors and people with disabilities who choose Medicare Advantage,” President and CEO Mary Beth Donahue, said in a statement. “We encourage CMS to work with stakeholders to put in place solutions that are transparent and fair to preserve stability for beneficiaries.”

The president and CEO of America’s Health Insurance Plans (AHIP), Matt Eyles, also was not happy. He called the rule “unlawful and fatally flawed, and it should have been withdrawn instead of finalized. The rule will hurt seniors, reduce health equity, and discriminate against those who need care the most.”

The problem of Medicare Advantage upcoding has increased over the years as MAOs have engaged in aggressive — and sometimes deceptive — marketing and television advertising campaigns that have enrolled millions of seniors. CMS is now trying to curtail such campaigns by employing secret shoppers and requiring that all calls with plan representatives be recorded.

By the end of this year, more than half of all Medicare beneficiaries will be enrolled in a Medicare Advantage plan, attracted by zero or low monthly premiums and the promise of other benefits like dental care, some prescription drug coverage, or gym memberships. However, the downsides of such plans are often poorly explained, and some beneficiaries find that when they need services — a trip to the doctor or a certain prescription — they may have to make unexpected and sometimes pricey co-payments.

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Claims Examiner- CHC/ Medicaid (Remote) in Pittsburgh, PA – UPMC

Clipped from: https://careers.upmc.com/jobs/12093305-claims-examiner-chc-slash-medicaid-remote?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

COVID-19 Vaccination Information

Across UPMC, our guiding principle is to always prioritize the safety of our employees, patients, and members. UPMC believes that vaccination is important, helps protect all, and advocates that everyone who can be vaccinated should be vaccinated.

UPMC complies with all governmental requirements related to local, state, and federal COVID-19 vaccination for employment. The Jan. 13 Supreme Court of the United States decision that the Centers for Medicare & Medicaid Services federal COVID-19 vaccine mandate will move forward requires UPMC to ensure employees either get vaccinated or receive a requested medical or religious exemption.

If you are not yet vaccinated, we urge you to get a vaccine now. You can schedule your COVID-19 vaccination through UPMC or visit a non-UPMC provider or UPMC Urgent Care location.

Proof of vaccination is not required upon hire; however, employees will be responsible for ensuring post-hire compliance by getting vaccinated or requesting a medical or religious exemption.

For more information about UPMC’s response to COVID-19, please visit UPMC.com/coronavirus.

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Description

UPMC Health Plan is hiring full-time Claims Examiners for our CHC department. In this position, you will
manage adjudication of moderate to complex claims while meeting or exceeding production and quality designated standards.

Our objective is to try to give members a better quality of life and studies have shown that people generally do better if they’re able to stay in their homes and communities.

This position is fully remote. (privilege eligibility is subject to continued achievement of business goals and on-site department needs).

Responsibilities:

 
 

  • Participate in training programs as available/requested;
  • Assist other departments during periods of backlogs;
  • Openly participate in team meetings, provide ideas and suggestions to ensure client satisfaction, and promote teamwork;
  • Process MCNet/Batch Edit errors in accordance with designated standards;
  • Maintain employee/insured confidentiality;
  • Work overtime as required per business need
  • Identify areas of concern that may compromise client satisfaction;
  • Maintain mail date integrity;
  • Process standard to moderate claims, including COB, in accordance with company policies and procedures in a timely manner while meeting or exceeding production and quality standards;
  • Resolve outstanding holds in accordance with designated standards;
  • Effectively prioritize and complete all assigned tasks

 
 

Qualifications

  • High school graduate or equivalent required.
  • One year of claims processing and/or equivalent education preferred.
  • Knowledge of medical terminology, ICD-9, and CPT coding required.
  • Knowledge of commercial, Medicaid, and Medicare products.Ability to use a QWERTY keyboard.
  • Competent in MS Office and PC skills preferred.
  • Working knowledge of COB (Coordination of Benefits) preferred.
  • Ability to demonstrate organizational, interpersonal, and communication skills.
  • Maintain designated production and quality standards required.
  • Previous computer experience in a professional setting is highly preferred. 

Licensure, Certifications, and Clearances:


UPMC is an Equal Opportunity Employer/Disability/Veteran

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At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct

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Security Alert

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If you suspect you have been a victim of a fraudulent UPMC job offer, please report the attempt using this form.