Compliance

Federal Watchdogs Raise Telehealth Fraud Concerns

The pandemic-induced telehealth revolution expanded access to an exciting new modality of care delivery, but a new report from federal watchdogs found that federal payers face new, telehealth-derived challenges in stopping waste, fraud and abuse. Those findings mean the commercial carriers that administer certain federally underwritten health insurance plans have a new auditing and accountability challenge as telehealth settles in as a permanent part of the care delivery landscape.

The report, prepared by six Offices of Inspectors General (OIGs) from HHS, the Dept. of Justice, Dept. of Defense, Dept. of Veterans Affairs (VA), Dept. of Labor and Office of Personnel Management (OPM), found that “while the expansion of telehealth has been essential to maintaining individuals’ access to care, there have been concerns about the potential for fraud, waste, and abuse associated with expanded telehealth services.”

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KHN Report Underscores Looming Issue of Extrapolation, FFS Errors in RADV Audits

After settling a three-year Freedom of Information Act (FOIA) lawsuit, Kaiser Health News (KHN) last month finally made public the results of multiple CMS audits of Medicare Advantage plans — which showed the federal government intends to collect an estimated $12 million for overpayments identified over a three-year period. KHN said it filed the lawsuit against CMS in September 2019, after the agency failed to respond to a FOIA request for the audits pertaining to care delivered between 2011 and 2013.

Those years represent the latest Risk Adjustment Data Validation (RADV) audits to be completed, referring to contract-level audits conducted by CMS to verify the accuracy of payments made to MA organizations and recover improper payments. Industry experts say the results obtained by KHN may not be representative of insurer practices today, and that they highlight the overarching question of whether the audit methodology that CMS may soon finalize aligns with the current payment and bidding system that’s in place for MA.

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OIG Audits Add to Debate Over Extrapolation in Recovering MA Overpayments

As the Medicare Advantage industry draws attention for millions of net overpayments identified in a recent Kaiser Health News report on audits conducted by CMS, the HHS Office of Inspector General in two new reports seeks to recover estimated MA overpayments for inaccurate diagnosis codes. Separate from the contract-level Risk Adjustment Data Validation (RADV) audits used by CMS to verify the accuracy of MA organizations’ risk adjusted payments, the OIG audits may further support the notion that MA plans are overpaid. They also exemplify insurers’ fierce opposition to the use of sampling to approximate a plan’s true payment error rate.

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Senate Democrats Push for MA Marketing Fixes, but Not All May Be Feasible

After releasing the results of their multistate probe into the marketing practices of Medicare Advantage plans and their partners, Senate Finance Committee Democrats are urging CMS to enhance its oversight of MA marketing and issue “commonsense” regulations as soon as possible. The report, Deceptive Marketing Practices Flourish in Medicare Advantage, illustrated dozens of “aggressive marketing tactics” in 14 states and advised CMS to take various measures within its regulatory reach. But industry experts tell AIS Health, a division of MMIT, that not all recommendations may be doable in the near term. And they say it’s likely CMS will see how recent efforts fare before pursuing steps such as prohibiting MA organizations from contracting with entities that purchase lists of leads.

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House Committee Calls Out Birth Control Coverage Barriers; Insurers Hit Back

In late October, the House of Representatives’ Committee on Oversight and Reform published a report that takes aim at managed care companies’ coverage of birth control products. Health policy experts say that while enforcement of the Affordable Care Act’s contraceptive coverage mandate has always been challenging, the new report comes as the Biden administration signals it is getting increasingly serious about cracking down on noncompliance. The insurers/PBMs mentioned in the report and the industry's main trade group, meanwhile, contend that they are in fact providing adequate coverage of contraceptives.

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CMS Spooks MA Plans With Warning About Secret Shopping, Enhanced Monitoring

If Medicare Advantage organizations and Prescription Drug Plans (PDPs) this open enrollment season have the haunting feeling they’re being watched, it’s because they are. After implementing new rules aimed at better protecting beneficiaries from confusing and misleading Medicare marketing, CMS in October issued two memos informing plans that they’ve done some digging into recent marketing activities and they don’t like what they’ve seen so far.

CMS has reported that marketing-related complaints more than doubled between 2020 and 2021 — which it largely attributed to the actions of third-party marketing organizations (TPMOs) — and has expressed particular concern with third-party marketers’ claims that some benefits are widely available to seniors when they vary by service area. To address these concerns, CMS made key changes this year, such as requiring TPMOs to use a standardized disclaimer that they do not offer every plan available in the area, clarifying that independent agents and brokers qualify as TPMOs, and stipulating that plans in their contracts with TPMOs require full recordings of sales calls with beneficiaries.

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Experts, Report Offer Ways to Supercharge Slow-to-Grow PACE Model

As the U.S. population ages and as payers and providers increasingly embrace home-based care — especially in light of the COVID-19 pandemic — a program that one expert calls the “best-kept secret in health care” seems poised to finally have its moment in the sun. However, there are a variety of barriers that need to be tackled in order for Programs of All-Inclusive Care for the Elderly to significantly grow, and recent compliance issues at the largest PACE participant raise questions about the involvement of private equity-owned, for-profit companies.

The PACE model employs comprehensive medical care and social supports to help frail, elderly Americans remain at home when they otherwise would require a nursing home level of care. Eligible enrollees — who never have to pay cost sharing — receive health care services at an adult day center, which is staffed with interdisciplinary care teams and also offers classes, games and other wraparound services.

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Medicaid Plans Aren’t Properly Reporting MLR Data, OIG Finds

Many of the medical loss ratio (MLR) reports that Medicaid managed care organizations are submitting to states are incomplete, and much of that missing data concerns how much MCOs are spending on administrative services, according to a new report from the HHS Office of Inspector General (OIG).

The report, published in September, is part of a “body of work” that the watchdog agency initiated a few years ago that focuses on the implementation of the federal MLR requirements for Medicaid managed care ushered in via the 2016 update to MCO regulations, the HHS-OIG Office of Evaluation and Inspections tells AIS Health via email. The new report builds upon a data brief issued in August 2021 that “served as a first-of-its-kind nationwide landscape of Medicaid managed care MLRs,” and found that most states established a minimum MLR of 85% for their contracted MCOs. That means plans must spend at least 85% of their premium revenue on covered health care services and quality improvement activities.

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New Third-Party Marketing Oversight Duties Have Industry Scrambling Before AEP

After observing a high volume of marketing-related complaints that the federal government believes are driven by the actions of third-party marketing organizations (TPMOs), CMS this month is implementing several new requirements aimed at protecting Medicare beneficiaries as they compare coverage options during the 2023 Annual Election Period (AEP) that starts on Oct. 15. And while one trade group is concerned that the changes may leave some independent agents and brokers out of the AEP, two marketing experts say they don’t anticipate a major shakeup and are hopeful that the changes will only weed out the bad actors.

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Medicaid Plans Aren’t Properly Reporting MLR Data, OIG Finds

Many of the medical loss ratio (MLR) reports that Medicaid managed care organizations submit to states are incomplete, and much of that missing data concerns how much MCOs are spending on administrative services, according to a new report from the HHS Office of Inspector General (OIG).

The report, published in September, is part of a “body of work” that the watchdog agency initiated a few years ago that focuses on the implementation of the federal MLR requirements for Medicaid managed care ushered in via the 2016 update to MCO regulations, the HHS-OIG Office of Evaluation and Inspections tells AIS Health via email. The new report builds upon a data brief issued in August 2021 that “served as a first-of-its-kind nationwide landscape of Medicaid managed care MLRs,” and found that most states established a minimum MLR of 85% for their contracted MCOs. That means plans must spend at least 85% of their premium revenue on covered health care services and quality improvement activities.

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