Medicare Compliance & Reimbursement

Warning: MA plans are now under OIG’s watchful eye.

Whether you’re new to Medicare Advantage (MA) or your organization’s been a provider for years, you should expect heightened scrutiny of the care you offer to your beneficiaries, a new HHS Office of Inspector General suggests.

“Our case file reviews determined that [Medicare Advantage Organizations] sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules,” the OIG says in a new report on the topic (OEI-09-18-00260). “MAOs also denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules,” the OIG continues.

Why it matters: “Denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers,” the OIG says in its report summary.

The “OIG investigated this issue because a central concern about the capitated payment model used in Medicare Advantage is the potential incentive for [MAOs] to deny beneficiary access to services and deny payments to providers in an attempt to increase profits,” note attorneys Sarah Ernst and Timothy P. Trysla with Alston & Bird in online legal analysis.

And the OIG appears to have uncovered just that. “We found that among the prior authorization requests that MAOs denied, 13 percent met Medicare coverage rules — in other words, these services likely would have been approved for these beneficiaries under original Medicare,” the OIG says. And “we found that among the payment requests that MAOs denied, 18 percent met Medicare coverage rules and MAO billing rules,” the watchdog agency adds.

For the bogus prior auth denials, “MAOs used clinical criteria that are not contained in Medicare coverage rules,” the OIG found. And while MAOs “indicated that some prior authorization requests did not have enough documentation to support approval … our reviewers found that the beneficiary medical records already in the case file were sufficient to support the medical necessity of the services.”

The invalid payment request denials occurred due to both human error during claims reviews and system errors in claims processing, the report says.

The report comes less than a month after the Centers for Medicare & Medicaid Services (CMS) finalized an 8.5 percent pay boost for MA plans in 2023 and a few days after the MA and Part D final rule was released (see related stories, p. 1 and p. 3). “CMS’ goals for Medicare Advantage … mirror our vision for the agency’s programs as a whole, which is to advance health equity; drive comprehensive, person-centered care; and promote affordability and the sustainability of the Medicare program,” the agency said in a release about the update.

Some lawmakers are now heeding those criticisms. “Medicare Advantage plans spend less on care while taxpayers pay more,” says a recent letter to CMS Administrator Chiquita Brooks-LaSure from a group of lawmakers headed up by Rep. Katie Porter (D-Calif.) and Sen. Elizabeth Warren (D-Mass.).

“Last year, CMS paid Medicare Advantage 4 percent more per enrollee than Traditional Medicare, despite the fact that Medicare Advantage plans spend up to 25 percent less on health care per enrollee,” the letter maintains. “According to [the Medicare Payment Advisory Commission], the combination of low bids and high payments creates a margin for benefits that ‘are shared exclusively by the companies sponsoring MA [Medicare Advantage] plans and MA enrollees.’”

MOAs “are paid on a capitation basis rather than fee-for-service,” explains the Physicians for a National Health Program (PNHP) group. “Once patients are enrolled, the insurers can increase their profits by denying requests for prior authorization of legitimate services or by simply denying payment for services that have already been provided in compliance with the rules. Prior studies have demonstrated that they do both, and this study from the OIG confirms that they continue to do so,” PNHP notes.

In the report, the OIG urges CMS to issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews; update its audit protocols to address the issues in the report; and direct MAOs to take additional steps to identify and address vulnerabilities that can lead to errors. In a response letter, CMS agrees.

As of January 2022, over 64.2 million people are enrolled in Medicare, CMS noted in an April 28 release. About 34.9 million are enrolled in Original Medicare, while 29.3 million — about 46 percent — are enrolled in Medicare Advantage or other health plans, according to CMS. “This includes enrollment in Medicare Advantage plans with and without prescription drug coverage,” the agency points out.

Resources: The 61-page OIG report is at https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf. The letter from lawmakers to Brooks-Lasure is at https://porter. house.gov/uploadedfiles/04-20-2022.kp_et_al_to_cms-brooks-lasure_re_medicare_advantage_payment_increase.pdf. Enrollment data is at https://data.cms.gov/summary-statistics-on-beneficiary-enrollment/ medicare-and-medicaid-reports/ medicare-monthly-enrollment.