Friday, July 10, 2015

Federal Audits Of Medicare Advantage Reveal Widespread Overcharges

Laughing Stock/Corbis

Government audits just released as the result of a lawsuit detail widespread billing errors in private Medicare Advantage health plans going back years, including overpayments of thousands of dollars a year for some patients.
Since 2004, private insurers that run Medicare Advantage plans, an increasingly popular alternative to traditional Medicare, have been paid using a risk scorecalculated for each patient who joins. Medicare expects to pay higher rates for sicker people and less for those in good health.
But the internal audits, never before made public, provide striking new evidence of billing mistakes — mostly overcharges — in the Medicare Advantage plans. Four of the audits were recently obtained by the Center for Public Integrity through a court orderin a Freedom of Information Act lawsuit.
The audits involve four health plans: an Aetna Health Inc. plan in New Jersey, Independence Blue Cross in the Philadelphia area; Lovelace Health Plan in Albuquerque, N.M, and a Care Plus plan in South Florida. Care Plus is a division of Humana, Inc.
Last month, the Center for Public Integrity reported on a fifth such audit at PacifiCare in Washington state, an arm of giant UnitedHealth Group, the nation's largest Medicare Advantage operator.
In all five audits, two sets of auditors inspected medical records for a sample of 201 patients at each plan for 2007. If the medical chart didn't document that a patient had the illnesses the plan reported, Medicare asked for a refund. Auditors also gave plans credit for underpayments they discovered.
Among the findings:
  • Medicare paid the wrong amount for 654 of the 1,005 patients in the sample, an error rate of nearly two-thirds. The payments were too high for 579 patients and too low for 75 of them. The total payment error topped $3.3 million in the sample.
  • Auditors concluded that risk scores were too high for more than 800 of the 1,005 patients, which in many cases, but not all, led to hefty overpayments. Medicare's annual payment for more than 200 patients was at least $5,000 higher than merited, according to the audits.
  • Auditors could not confirm one-third of the 3,950 medical conditions the health plans reported, mostly because records lacked "sufficient documentation of a diagnosis." The names of the medical conditions were redacted by federal officials.
The federal Centers for Medicare and Medicaid Services, or CMS, which conducted the audits, had no comment.
None of the health plans would discuss the audit findings. Aetna, in a statement, said the company had "raised a number of questions and concerns" regarding the results and was "awaiting a response from CMS."
Clare Krusing, a spokeswoman for America's Health Insurance Plans, the insurance industry's primary trade group, said the audits "overstated" the payment errors. Health plans have since improved their record keeping and offer better care for people with chronic health conditions than traditional Medicare, Krusing said.
"The evidence is overwhelmingly clear that these programs (Medicare Advantage) deliver the right care for beneficiaries," she said.
The records are coming to light at a time of rapid expansion — and consolidation — in the Medicare Advantage market. Enrollment has neared 17 million, about 1 in 3 people eligible for Medicare. Last week, Aetna announced plans to buy competitor Humana for $37 billion.
But the industry also is drawing scrutiny over the accuracy of risk-based payments—and a penchant for secrecy.
The Center for Public Integrity first reported last year that billions of tax dollars are wasted every year due to plans that appear to exaggerate how sick their patients are, a practice known as "upcoding."
The government audits, known as Risk Adjustment Data Validation, or RADV, are the government's primary tool for catching these sorts of billing mistakes and holding the industry accountable.
Yet the process has proven unwieldly at best, partly due to a complex and lengthy appeals process and partly to indecision over how much the health plans should refund to the government.
It's not clear how the five audits were settled because CMS officials have refused to release these records.
The five RADV audits were launched in 2008, but findings weren't issued until August 2012, when CMS officials sent each plan a form letter detailing the amount of the overpayment and the plan's extensive appeal rights. CMS has refused to make public the status of the audits—or even how many total RADV audits have been conducted. CMS cites an exemption to the Freedom of Information Act that shields "trade secrets."
This stance has largely concealed Medicare Advantage billing records. It wasn't until April 15, 2011, that CMS announced it would release minimal billing data annually. Doing so would "inform the public on how their tax dollars are being spent," the agency said at the time, citing President Obama's January 2009 Memo on Transparency and Open Government.
But much to the chagrin of some researchers, CMS has never expanded on what is released, even though it has made public a huge cache of billing data and audits centering on thousands of doctors, hospitals and other medical suppliers.
"It's astonishing," said Brian Biles, a professor at George Washington University who successfully sued CMS to win release of the limited billing data now available. "They are dumping huge amounts of data in other areas. Medicare Advantage is now 30 percent of the Medicare program." (Biles assisted the Center for Public Integrity with its 2014 analysis of that data.
Timothy Layton, a Harvard Medical School researcher who recently co-authored a paper on health plan upcoding, said scholars "are definitely hindered" by the lack of data. For instance, researchers can't examine individual risk scores and the various medical conditions that raise and lower them, he said.
"Without the ability to answer these questions, we can keep pointing out how big the overpayment to MA (Medicare Advantage) is, but we can never really provide the optimal solution to the problem," Layton said.
David Himmelstein, a physician and professor in the CUNY School of Public Health at Hunter College who supports a single payer medical system, agreed.
"Medicare publishes detailed data on almost every doctor and hospital that gets paid a penny, but it leaves the public — and researchers — almost completely in the dark about the giant Medicare Advantage plans that will collect more than $150 billion from Medicare this year," he said.
Still, Medicare Advantage insurers are facing calls for closer scrutiny of their operations. In May, Senate Judiciary Committee Chairman Charles Grassley, R- Iowa,wrote to Attorney General Loretta Lynch and CMS administrator Andrew Slavitt asking how many risk score fraud investigations had been conducted over the past five years and their results. He's still waiting for an answer.
"Sen. Grassley continues to expect responses to his letters and will continue to press for responses," said Grassley spokeswoman Jill Gerber. "This is an important issue involving a large amount of taxpayer money"
In a separate letter, Sen. Clare McCaskill, the senior Democrat on the Senate Aging Committee, asked CMS officials to advise her of government efforts to curb Medicare Advantage billing abuses.
"After meeting with CMS we have continued concerns about the level of oversight taking place with respect to Medicare Advantage plans and will continue working to increase oversight and accountability in this area," said McCaskill spokesman Drew Pusateri.
This piece comes from the Center for Public Integrity, a nonpartisan, nonprofit investigative news organization.

Tuesday, July 7, 2015

CMS: No ICD-10 Audit Claims for Specificity in Year One

For one year after implementation of ICD-10, CMS will not deny or audit claims just for specificity, as long as the code is from the appropriate family of ICD-10 codes. Similarly, physicians will not be penalized for the value-based payment modifier or Meaningful Use due to specificity of diagnoses.

After a vigorous, last-ditch push by the AMA for a two-year transition period after implementation to protect physicians from all ICD-CM coding errors and mistakes, CMS and AMA made a joint announcement that appears to signal a burying of the hatchet.

Steven Stack, MD, AMA's president, touts the changes in a post that begins with a concession his group has resisted stating for years: "Implementation of the ICD-10 code set is just around the corner, with a hard deadline of Oct. 1."

To gain that admission from the AMA, CMS agreed to a variety of policies involving claim denials, quality reporting, payment disruptions, and navigating the transition.

For one year after implementation, CMS will not deny or audit claims just for specificity, as long as the code is from the appropriate family of ICD-10 codes.  Even though the use of unspecified codes is allowed according to the ICD-10-CM Official Guidelines for Coding and Reporting, this clarification makes a lot more sense than absolving physicians of all coding errors and mistakes.

Similarly, CMS will not penalize physicians for the Physician Quality Reporting System, the value-based payment modifier, or meaningful use to due specificity of diagnoses as long as the provider reports a code from the appropriate family.

CMS has also authorized advance payments to physicians if Medicare contractors can't process claims due to problems related to ICD-10.

CMS will continue to offer resources to aid practices with a new ICD-10 communications and coordination center headed by an ombudsman to resolve outstanding questions about implementation.
For more information, see CMS' guidance on the changes.

The biggest benefit to the healthcare community is that the announcement has finally removed the biggest barrier to implementation: uncertainty. You can now talk to physicians confidently about the ICD-10 deadline and work with them throughout the yearlong transition to improve their documentation for you to choose the most appropriate, and specific, code.

You can forget about delays, waiting for ICD-11, and any other excuses you've heard about pushing off training for the transition. With the AMA and CMS working together, ICD-10 is certainly coming in just 86 days.

Friday, July 3, 2015

CMS proposes a few clarifications to its chronic care management billing code

At the beginning of 2015, CMS began reimbursing physicians for the care they provide to a particular group of their Medicare patients remotely and between visits. This new billing code, called Chronic Care Management (CCM), required that this remote care meet a few criteria, like patients must have two or more chronic conditions; the physician must establish a comprehensive care plan for the patient; and the remote care must take up at least 20 minutes of staff time over the course of the month.

This week CMS issued a proposed rule that seeks to clarify the use of the CCM billing code based on the many inquiries the agency has received since the code first came out.

“In reviewing the questions from hospitals on billing of CCM services, we identified several issues that we believe need to be clarified. Therefore, for CY 2016 and subsequent years, we are proposing additional requirements for hospitals to bill and receive OPPS payment for CPT code 99490. These proposed requirements, discussed below, are in addition to those already required…” CMS writes. 

CMS proposes that starting next year CCM can only be billed to if patient has an already established relationship with the provider using the code. “While we have always expected the hospital furnishing the clinical staff portion of CCM services, as described by CPT code 99490, to have an established relationship with the patient and to provide care and treatment to the patient during the course of illness… we have not previously specified through notice-and-comment rule making that the hospital must have an established relationship with the patient as a requirement for billing.” This prior relationship requirement would be an “explicit condition” on billing to the code, if the proposal is adopted.

CMS also wanted to clarify that while it was previously stated that only one physician can bill for the code for a given patient, the same goes for one hospital for a given patient. “The physician or other appropriate non-physician practitioner directing the CCM services should inform the beneficiary that only one hospital can furnish and be paid for these services during the calendar month service period.”

For more on CMS’ proposed changes and clarifications to CCM and other billing codes, check out the full proposal here (PDF).