Late last month, in Modern Healthcare, Jessie Hellmann writes that Jonathan Blum of the Center for Medicare and Medicaid Services (CMS) now echoes the concerns of those in the Office of Inspector General (OIG) regarding risk adjusted revenue integrity. According to an OIG report, some Medicare Advantage Organizations (MAOs) may have leveraged chart reviews and Health Risk Assessments to potentially exaggerate the negative health status of members. Because revenue in the program is risk adjusted, these representations have likely resulted in excess and inappropriate revenue for the MAOs.

“Unsupported risk-adjusted payments have been a major driver of improper payments in the MA program,” said Blum.

Blum also expressed concern for “the overall trend lines for code growth in the MA program vs the fee-for-service program” and mentioned possible regulation.

The OIG noted a specific finding that “… 20 of the 162 MA companies drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and HRAs, and on no other service records.”

Much of this derives from OIG’s December 2019 report entitled “Billions in Estimated Medicare Advantage Payments from Chart Reviews Raise Concerns.”  To develop this report, OIG cites this review methodology:

We analyzed 2016 MA encounter data to determine the 2017 financial impact of diagnoses reported only on chart reviews and not on any service record in the encounter data that year. We also analyzed CMS’s responses to a structured questionnaire to identify actions taken by CMS to review the impact of chart reviews on MA payments.

With this report in mind, OIG made the following recommendations to CMS:

(1) provide targeted oversight of MAOs that had risk-adjusted payments resulting from unlinked chart reviews for beneficiaries who had no service records in the 2016 encounter data.

(2) conduct audits that validate diagnoses