The country’s largest Medicare Advantage carriers are backing significant proposed reforms to billing practices, along with new crackdowns and audits of the plans.
CMS Administrator Mehmet Oz, MD, has promised scrutiny of the Medicare Advantage program amid allegations of widespread fraud. In May, CMS said it would audit every MA plan for potential overpayments annually, in what the agency called an “aggressive” plan to step up oversight.
UnitedHealth Group, the largest MA insurer, said it supports CMS auditing each MA plan annually, a policy it has “long publicly advocated for.”
“We look forward to working with CMS to develop an accurate methodology and appropriately use advanced technology to greatly enhance the auditing process,” the company said May 21.
The Better Medicare Alliance, a pro-MA group backed by insurers, also supports the new policy.
“Medicare Advantage already includes strong accountability mechanisms and consistently enforcing them will help the program work even better for seniors and taxpayers alike,” President and CEO Mary Beth Donahue said in a statement shared with Becker’s.
Meanwhile, Humana is backing MA reforms aimed at reducing billing practices that result in billions of extra payments to the broader industry, The Wall Street Journal reported June 5.
“Seniors love Medicare Advantage because it delivers great care and can make healthcare easier,” CEO Jim Rechtin told the outlet in a statement. “But we know we can make it better and we want to work with Congress and the Trump Administration on responsible solutions.”
According to the report, Humana is willing to back measures that would limit the payments insurers can receive from diagnoses made by nurse practitioners during home visits and has proposed that extra payments should only be allowed for diagnoses recorded during home visits if they are also documented elsewhere, such as a visit with another provider. The company has also suggested restricting payments for diagnoses obtained solely through chart reviews without a specific medical encounter.
MA plans are paid by the federal government based on enrollees’ health status, with sicker enrollees receiving higher reimbursement. Most major MA insurers have faced allegations or settlements related to upcoding in recent years, and calls for stronger oversight have gained bipartisan momentum.
CMS conducts risk-adjustment data validation audits to confirm the diagnoses MA plans bill the federal government for are backed by health records. The Medicare Payment and Advisory Commission estimates MA plans could receive up to $43 billion in overpayments from diagnoses not backed by medical records each year.
“There’s a lot of concern on Capitol Hill about Medicare Advantage,” Sen. Roger Marshall, MD, R-Kan., told Bloomberg Television on June 5. He pointed to bipartisan legislation introduced in March by Sens. Bill Cassidy, MD, R-La., and Jeff Merkley, D-Ore., that aims to tighten diagnosis coding regulations and could yield up to $275 billion in savings over 10 years, according to lawmakers.
