Article of Interest
Article
Title: Upcoding
in Medicare Advantage: Transparency can clean the mess
Author:
That the government overpays sellers of Medicare
Advantage plans is well known in Beltway circles even if much of the public
remains unaware. Recently, two Department of Health and Human Services (HHS)
researchers posted new findings on the Medicare and
Medicaid Research Review, a peer-reviewed online journal
supported by the Centers for Medicare and Medicaid Services (CMS), documenting
how some insurance companies are overbilling the government and have been doing
so for years.
Fred Schulte, a senior writer
for the Center for Public Integrity who has been covering overbilling in the
Medicare Advantage program, told me he spotted the new study while he was just
cruising around the CMS website. “Despite its broad implications for Medicare
spending, the study by HHS researchers Richard Kronick and W. Pete Welch has
attracted scant notice in Washington,” Schulte wrote.
The Medicare Advantage program, which is growing rapidly,
costs the government some $160 billion a year, so waste in the program can add
up to real money. Recall that Medicare Advantage plans were promoted as a way
for private insurers to provide the basic Medicare benefits and to save the
government money by providing care coordination, especially for seniors with
multiple chronic conditions. Generous payments from the government have allowed
insurers to offer low- or no-premium plans and lots of extras, like dental care
and eyeglasses, which help account for their popularity. About 16 million
seniors are enrolled in a Medicare Advantage plan, almost one-third of all
Medicare beneficiaries.
In June, the Center for Public Integrity published
the results of its investigation showing that billions of tax dollars
are misspent each year because of billing errors linked to payment tools called
risk scores, which are at the heart of the recently published HHS study. In
order to prevent Medicare Advantage health plans from trying to avoid covering
high-risk participants, Medicare has been using a payment scheme based on
diagnostic codes and adjusting payments to the plans accordingly. Health plans
get more money for beneficiaries who need more care.
But as the General Accounting Office has pointed out,
this payment method designed to solve one problem has simply created another:
Medicare Advantage plans have learned to game the system to pad their
reimbursements, a process called upcoding. That’s hardly surprising given the
history of fraud and other unsavory practices in the program on the part of
providers and insurers.
The HHS researchers found unexpectedly high risk scores
for Medicare Advantage beneficiaries for conditions such as alcohol and drug
dependence, complications of diabetes, and depression. For example, they found
that drug and alcohol dependence is as much as eight times more common in the
Medicare Advantage health plans that upcode the most than it was among
beneficiaries who remained in traditional Medicare. The researchers also
concluded that people who join Medicare Advantage plans are generally healthier
than those who remain in the traditional fee-for-service program.
Will the HHS researchers’ study be a wake-up call for CMS
and the Obama administration to finally crack down on the overpayments to
Medicare Advantage plans? Remember, that was something the president vowed to
do when he was campaigning for office. But in the last two years, each time the
agency proposed cutting payments to Medicare Advantage plans, lobbying
campaigns by the industry won out and those proposed cuts turned into
payment increases.
Maybe there’s another route to cleaning up this mess:
transparency. The researchers did not name the companies noted for upcoding the
health risks and conditions of beneficiaries, but suggest that these are
insurers with lots of Medicare customers. One of the highest billers had more
than 200,000 policyholders. There’s always a chance public shame will help do
the trick.
AccuChecker Introduces MCAR
MCAR Reports -
Managed Care Reports
We are
proud to introduce MCAR REPORTS a complete set of management reports for IPAs,
MSOs and PCP Practices that have Risk Agreements with HMOs Plans. The MCAR
Reports give you complete awareness over what is happening with every HMO Plan
that your organization participates in risk operations.
MCAR -
MANAGED CARE REPORTS is an online service available created from data files
downloaded from HMOs servers. Within 24 to 48 hours our team produces all
reports needed to manage your risk business. MCAR Reports are viewed from our
secured HIPPA compliant servers however most reports are downloadable in EXCEL
format files.
MCAR
Reports services can range from only generating reports to having our
management team assisting clients in managing the risk operations.
Clients
can select MCAR Report services “A LA CARTE” choosing monthly reports needed
and/or consulting services they prefer.
Here are some of the options available:
Here are some of the options available:
·
Control over HEDIS requirements, alerting what
measures apply to each member of the HMO panel and most importing identifying
what measures are pending per member in the reporting period.
·
Summary analysis of funding and expenses including
expected distributions, in minutes you know what is going on with your risk
operation.
·
A PCP Analysis that shows performance for each PCP in
the network from funding, expenditures to net amount after medical expenses. A
simple and easy report that enables you to identify and compare all PCP’s
performance.
·
MCAR produces a detailed analysis of charges payments
and adjustments from Institutional, Professional and Pharmacy claims.
·
A key report - Summary Report showing what each member
is costing the panel, a brief breakdown of medical expenses also showing when
was the last time the patient came to the office, if ever.
·
A detailed analysis showing all activities for every
member - HEDIS measure status, diagnosis codes with MRA evaluation plus each
line item of expenses – YOU CAN VIEW THE PRECISE COST OF EACH MEMBER OF THE
PANEL.
·
STOP LOSS verification.
·
MCAR Reports claims module – “The ADJUDICATOR” scrubs
your professional, institutional and pharmacy claims and also prepares a
contestation report requesting adjustments from the Plan.
·
The
ADJUDICATOR module employs the most sophisticated scrubbing techniques
following CMS and AMA guidelines in processing professional and pharmacy
claims.
For more
information, please contact 305-227-2383 , 1-877-938-9311 or 786-574-4560
Feel free to glance :
www.accuchecker.com
Paul G. Silverio-Benet
BE PART OF OUR SOCIAL SITE – FEEL FREE TO JOIN
No comments:
Post a Comment