Tag: Medicare Advantage

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Health Law Highlights

Fifth Circuit Grants Motion Relating to New CMA Compensation Rule

Summary of article from Troutman Amin, LLP, by John H. Henson:

On July 3, 2024, the US District Court of Northern Texas issued a Memorandum Opinion and Order in the combined cases challenging new CMS rules regarding compensation for Medicare Advantage and Part D plans. The court found the compensation changes to be arbitrary and capricious, granting a partial stay on these rules but allowing the consent requirement for sharing beneficiary data to proceed. The decision highlights the court’s scrutiny of the CMS rulemaking process and indicates a substantial likelihood of the plaintiffs’ success on the merits. However, the consent requirement remains in effect, necessitating prior express written consent for data sharing between third-party marketing organizations. This ruling does not impact the FCC’s 1:1 consent requirement, which remains distinct and unaffected.

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OIG Testimony Puts a Spotlight on Clinical Documentation and Payer Risk

Summary of article from Ankura, by Emily Petersen:

In a recent testimony, the Inspector General of the Department of Health and Human Services (HHS), highlighted issues surrounding risk adjustment in Medicare Advantage (MA) and proposed stricter rules for diagnoses used in risk adjustment calculations. She underscored the issue of rising improper payments within Medicare and Medicaid, emphasizing the need for increased oversight and enforcement. Significant vulnerabilities in the MA risk adjustment process and challenges in Medicaid Managed Care were also discussed, with a call for organizations to review their medical records and ensure the accuracy of diagnosis codes. Furthermore, systemic weaknesses such as eligibility determination errors and duplicate payments were pointed out, requiring urgent attention. Lastly, Grimm emphasized the need for increased investment in oversight and enforcement to combat fraud, waste, and abuse in healthcare programs.

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Health Law Highlights

Humana Can Challenge Medicare Clawback Rule

Summary of article from Reuters, by Brendan Pierson:

Humana can proceed with its lawsuit against a Biden administration rule that enables Medicare to reclaim overcharges from insurers. The rule, established in January 2023, permits the government to recoup payments to Medicare Advantage plans when audits reveal charges for diagnoses not present in patients’ medical records. The Biden administration believes this could help recover around $4.7 billion over a decade. Humana argues the rule is “arbitrary and capricious,” with potential unforeseen consequences for Medicare Advantage organizations and beneficiaries. The judge rejected the administration’s request to dismiss the case, stating that the perceived risk of future harm was enough to establish standing.

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Health Law Highlights

CMS Finalizes its Proposal to Advance Interoperability and Improve Prior Authorization Processes

From Sheppard Mullin Richter & Hampton LLP, by Gianfranco Spinelli and Krysten Thomas:

  • Final Rule Issued by CMS: The Centers for Medicare and Medicaid Services (CMS) issued a final rule titled “CMS Interoperability and Prior Authorization” on January 17, 2024, which aims to advance interoperability and improve prior authorization processes. This rule impacts Medicare Advantage organizations, state Medicaid and CHIP agencies, Medicaid and CHIP managed care plans, and plans on the Affordable Care Act exchanges, as well as MIPS eligible clinicians, and eligible hospitals and critical access hospitals.
  • Patient Access API: The final rule requires Impacted Payers to provide patients access to certain information, including claims, cost sharing data, encounter data, and a set of clinical data accessible via health applications. The implementation of this requirement is set for January 1, 2027, which is a change from the original proposed date of January 1, 2026.
  • Provider Access API and Payer-to-Payer API: The rule mandates Impacted Payers to build and maintain a Provider Access API for data sharing with in-network providers. It also requires a Payer-to-Payer API to ensure patients can maintain continuity of care and have uninterrupted access to their health data. Both these requirements are to be implemented by January 1, 2027.
  • Prior Authorization API and Process Improvements: CMS finalized the proposal to require Impacted Payers to build and maintain a Prior Authorization API, which is to be implemented by January 1, 2027. The rule also shortens the time frames for prior authorization decisions and requires Impacted Payers to provide a specific reason for denied decisions. These requirements are to be complied with by January 1, 2026.
  • Public Reporting and Electronic Prior Authorization Measure: The final rule requires Impacted Payers to publicly report certain prior authorization metrics, with the initial set of metrics to be reported by March 31, 2026. It also mandates MIPS eligible clinicians, eligible hospitals, and CAHs to report the number of prior authorizations for medical items and services requested electronically from a Prior Authorization API.
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Health Law Highlights

What Cigna’s FCA Settlement Means for Other Medicare Advantage Plans

From HealthPayerIntelligence, Victoria Bailey:

  • Cigna’s recent brush with False Claims Act violations serves as a reminder that Medicare Advantage organizations should be routinely assessing their risk and compliance activities.
  • The United States alleged that Cigna submitted inaccurate and untruthful patient diagnosis data to receive additional payments from CMS and did not withdraw the inaccurate data or repay CMS.
  • Cigna submitted the diagnoses to CMS even though they were not supported by information documented on the vendors’ forms, nor were they reported to Cigna by other healthcare providers who saw the patient during the year the home visits occurred.
  • Medicare Advantage is a top priority for the government when it comes to detecting fraud.
  • Medicare Advantage plans should focus on risk mitigation assessments to avoid similar situations:
    • ensure your documentation looks good. Make sure if you’re doing these retrospective reviews of patient charts, you’re not just adding codes, but also making sure that if any of the codes needed to be downgraded, you’re deleting those extra codes
    • look at their data and imagine how it would appear to an objective third party. Plans should ensure they are identifying the correct codes and that any in-home assessments are complete.
    • conduct annual risk assessments and other monitoring.
  • All Medicare Advantage organizations would benefit from proactively assessing their data on a routine basis. Some organizations may be able to monitor their documentation and conduct risk adjustments with their current staff. However, partnering with outside companies may be helpful for others.
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Health Law Highlights

Congress Eyeing Broker Payments Behind Booming Medicare Sales

From Bloomberg Law, by John Tozzi:

  • About 31 million people – more than half of Medicare enrollees – opt to get their coverage through private plans known as Medicare Advantage.
  • Lawmakers are examining the payments made by health insurers to brokers who sell their Medicare plans, concerned that the payments may be steering seniors to some plans over others.
  • Federal rules limit the commissions Medicare plans can pay brokers, but some companies may be skirting these rules by offering extra payments that can sometimes double brokers’ compensation, influencing them to push plans that pay the most.
  • A report from the Senate Finance Committee last year described deceptive marketing tactics, “fraudulent sales practices,” and instances of people being enrolled in Medicare Advantage plans without knowing it.
  • The large, publicly traded online brokers report revenue from both commissions and other sources, such as “volume-based bonuses” for meeting sales targets and “marketing development funds” for certain customers.