Tag: CMS

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Justice Department accuses Anthem of Medicare fraud

Yet another allegation of Medicare Advantange risk adjustment fraud, this time by Anthem. I wrote about the government’s case against Cigna here.

The case alleges that Anthem falsely certified the accuracy of the diagnostic data it sent to the Centers for Medicare and Medicaid Services, causing CMS to calculate risk-adjustment payments to the insurer based on inflated diagnosis information. For example, Anthem submitted an ICD-9 diagnosis code for active lung cancer for one patient, but its chart review program did not substantiate the diagnosis, according to court documents.

Source: Justice Department accuses Anthem of Medicare fraud

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CMS Encourages Faster COVID-19 Diagnostic Testing

CMS is changing its payment methodology to encourage higher throughput of COVID-19 diagnostic testing. Previously, CMS would reimburse $100 per test

Starting January 1, 2021, Medicare will pay lower the base rate to $75. However, if the laboratory can complete the test within two (2) calendar days from the date the specimens is collected, CMS will reimburse an additional $25 for a total of $100 per test.

To be entitled to this $25 incentive, the laboratory must: a) complete the test in two calendar days or less, and b) complete the majority of their COVID-19 diagnostic tests that use high throughput technology in two calendar days or less for all of their patients (not just their Medicare patients) in the previous month.

Source: Press release: CMS Changes Medicare Payment to Support Faster COVID-19 Diagnostic Testing

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DOJ sues Cigna, alleging $1.4B in Medicare Advantage fraud

Cigna falsified the health conditions of its Medicare Advantage plan members to coax CMS into making larger payments to the insurer on behalf of beneficiaries, a U.S. Justice Department lawsuit alleges.

Medicare Advantage organizations get reimbursed by Medicare based on a formula that takes into account the patient population’s acuity levels. Risk adjustment scores adjust for health conditions so that more reimbursement levels are higher for more costly or chronically ill populations.

The risk adjustment scores have become a source of potential fraud. If the scores are not accurately calculated, MA organizations can receive more reimbursement than their populations warrant. The scores are calculated by CMS based on information provided by the MA organization about the patients health conditions. If the health information provided by the MA organization is inaccurate, so too will be the risk adjustment scores derived by CMS.

Cigna uses a medical assessment system called “360” to assess the health condition of its patients, but this system did not require the providers to state whether the patient’s condition was derived from a clinical assessment or the patient’s subjective description.

CMS alleges that Cigna received an estimated $1.4 billion from 2012 to 2017 and DOJ is seeking equal to three times that amount in damages, along with a civil penalty of $11,000 for each violation.

Source: DOJ sues Cigna, alleging $1.4B in Medicare Advantage fraud

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CMS Issues Cease and Desist Orders to Uncertified Labs Performing COVID-19 Testing

Since August 12, 2020, CMS issued 171 cease and desist letters to entities across the U.S. that were testing for COVID-19 without the appropriate certifications under the Clinical Laboratory Improvement Amendments of 1988 (CLIA).

Every facility that conducts COVID-19 testing is considered a “laboratory” and must be certified under CLIA, which verifies that labs meet federal performance and quality standards to help ensure they provide reliable results.

According to CMS, 34% of the labs that were ordered to stop testing were operating without a CLIA certificate, while the remaining 66% were performing COVID-19 testing outside the scope of their existing CLIA certification. The letters provided non-certified labs with information on how to become CLIA certified and encouraged certified labs to obtain proper CLIA certification so they could resume COVID-19 testing.

Source: CMS Takes Action to Protect Integrity of COVID-19 Testing