7 reactions to CMS' Medicare Advantage audit ruling

Organizations representing payers say tougher auditing standards CMS will impose on Medicare Advantage plans could create higher premiums and fail to target fraud. Others say the new rule, which eliminates the fee-for-service adjuster, doesn't go far enough. 

CMS published its final rule on Medicare Advantage risk adjustment data validation audits Jan. 30. The new standards mean MA plans could be on the hook for billions in payments to the federal government, but the rule will only be applied to audits for contracts from 2018 on. Earlier versions of the proposed rule indicated the agency would apply the auditing standards as far back as 2011. 

Here's what seven industry leaders and officials had to say about the ruling. 

  1. Matt Eyles, president and CEO of AHIP, said the rule would "would raise prices for seniors and taxpayers, reduce benefits for those who choose MA, and yield fewer plan options in the future."

    "We encourage CMS to work with us, continuing our shared public-private partnership for the health and financial stability of the American people," Mr. Eyles continued. "Together, we can identify solutions that are fair, are legally sound, and ensure uninterrupted access to care and benefits for MA enrollees." 

  2. Mary Beth Donahue, president and CEO of the Better Medicare Alliance, a pro-MA group representing industry stakeholders, said the rule has a "potential unintended consequence" of creating higher premiums and fewer benefits in MA.

    "We encourage CMS to work with stakeholders to put in place solutions that are transparent and fair to preserve stability for beneficiaries," Ms. Donahue said. 

  3. David Merritt, senior vice president of policy and advocacy of the Blue Cross Blue Shield Association, called the new regulation "overreaching" and said CMS should have chosen a "narrower solution aimed at a few bad actors."

    "While we all can agree that improvements can be made, the failure to adjust for the legitimate differences between Medicare Advantage and original Medicare will have a detrimental effect on the seniors and people with disabilities who rely on the Medicare Advantage program," Mr. Merritt said. 

  4. Chiquita Brooks-LaSure, CMS administrator, said the ruling protects Medicare "now and for future generations."

    "We have considered significant stakeholder feedback and developed a balanced approach to ensure appropriate oversight of the Medicare Advantage program that aligns with our oversight of Traditional Medicare," Ms. Brooks-LaSure said.

  5. Ceci Connolly, president and CEO of Alliance of Community Health Plans, said the rule "fails to target the most egregious diagnosis coding violations." 

    "We believe that our members submit accurate risk adjustments for beneficiaries and are upfront in correcting errors when found," Ms. Connolly said. We are disappointed by the final regulation and hope CMS reconsiders more targeted approaches to meaningfully address compliance in the MA program and protect the taxpayer dollar."

  6. Ted Doolittle, former deputy director for policy and enforcement at CMS, told Kaiser Health News the rule is "good news" but could have gone further.

    "I do wish they were pushing back further [and extrapolating earlier years]. That would seem to be fair game," Mr. Doolittle said. 

  7. Gary Taylor, analyst at Cowen, told The Wall Street Journal the ruling isn't what payers were hoping for but spares companies from "retro risk" by further extrapolating auditing years.

    "It’s definitely a mixed bag of results for the industry," Mr. Taylor said. 

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