Risk Adjustment

2022 Outlook: MAOs Face Payment Unknowns, Increased Competition This Year

For the Medicare Advantage industry, change wasn’t a major outcome of the Biden administration’s first year in office. But for 2022, MA organizations face a host of unknowns — such as potential risk adjustment and star ratings changes that could impact plan revenue — and challenges that include staying competitive in an increasingly rich benefits landscape. For AIS Health’s annual roundup of perspectives on the year ahead, industry experts weigh in on how doing business in 2022 might differ from previous years.

AIS Health: What do you view as some of the biggest challenges or uncertainties facing MAOs in 2022?

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2022 Outlook: MAOs Face Payment-Related Unknowns, Increased Competition

For the Medicare Advantage industry, change wasn’t a major outcome of the Biden administration’s first year in office. But for 2022, MA organizations face a host of unknowns — such as potential risk adjustment and star ratings changes that could impact plan revenue — and challenges that include staying competitive in an increasingly rich benefits landscape. For AIS Health’s annual roundup of perspectives on the year ahead, industry experts weigh in on how doing business in 2022 might differ from previous years.

AIS Health: What do you view as some of the biggest challenges or uncertainties facing MAOs in 2022?

Recent MA Coding Complaints Signal DOJ’s ‘Evolving Expectations’

The risk adjustment system used to pay Medicare Advantage plans continues to face intensifying scrutiny from the federal government, with the Dept. of Justice (DOJ) intervening in multiple False Claims Act (FCA) complaints and the HHS Office of Inspector General focusing on retrospective chart reviews and high-risk diagnosis codes. Now, attorneys say health care providers should be on high alert as well. While prior DOJ complaints-in-intervention have focused largely on MAOs conducting “one-way” chart reviews, more recent lawsuits focus on the use of “addenda” — information retroactively added to a patient’s medical record — which one law firm says indicates a new area of scrutiny.

Latest OIG Risk Adjustment Audit Seeks $6.4 Million From UPMC

Continuing a series of audits in which the HHS Office of Inspector General is reviewing the accuracy of diagnosis codes submitted to CMS by Medicare Advantage organizations, OIG last month said most of the codes it reviewed for UPMC Health Plan, Inc. could not be validated by medical records. The agency used its own extrapolation methodology to estimate that the Pittsburgh-based insurer owes $6.4 million for the 2015 and 2016 payment years, prompting a detailed rebuttal from UPMC and adding to the ongoing debate over the use of sampling to approximate a plan’s true payment error rate.