Medicare Advantage: No Apparent Advantage for Some

Complaints are abundant from beneficiaries.

Last week saw the release of another audit of a Medicare Advantage (MA) plan from the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG).

As a reminder, the OIG often audits the diagnoses submitted to the Centers for Medicare & Medicaid Services (CMS) as hierarchical condition categories (HCCs) that influence the monthly payment they receive from CMS for each patient. And as you have heard here, they often find that the MA plans have submitted many unsubstantiated diagnoses resulting in significant overpayments, into the tens of millions of dollars. Well, in this audit, the OIG found that Cigna’s Florida MA plan, called HealthSpring, had about a four percent error rate. That is outrageously good. In a report of another MA plan last year, they OIG found an 82 percent error rate.

Yet Cigna apparently was not satisfied because even with these stellar results, the OIG still tried to extrapolate the results. They submitted a 33-page rebuttal criticizing almost every part of the audit including the sample size and of course the use of extrapolation. They even strayed into areas that were unrelated to the audit, including criticizing CMS for the Kwashiorkor diagnosis fiasco several years ago, for the way CMS mapped sepsis as an HCC, and for the CMS policy of not allowing documentation from a home health agency or DME supplier to be used for diagnosis validation purposes.

The tone of this audit was harsh but apparently it worked. After adjusting a few findings, the OIG determined extrapolation was not warranted and determined their overpayment was only $39,000 and not $10 million.

By the time you read this we will have passed the deadline for submitting comments to CMS about improving the MA plan program, and the comments are pouring in. As of August 29, CMS had posted 633 of the comments for public viewing. For fun I took some time and read some of them.

The first comment on page 1 was my comment. In my comment I took up the theme that was echoed by many other comments, the lack of consistent standards for determining admission status for MA patients and the lack of discharge appeal rights for the MA patients stuck in observation for days on end. But there were many other topics addressed by a wide variety of commenters. Many providers, from physicians to case managers to beneficiaries, commented on the delays imposed by MA plans to get approval for post-acute care and how that hinders full recovery and adds risk of developing a hospital-acquired infection.

Many beneficiaries wrote about their difficulties accessing necessary services with onerous prior authorization processes and limited provider networks. Beneficiaries also complained about the incessant calls and commercials advertising MA plans. Physicians from a wide range of practices complained about their inability to treat the patients as they felt was medically indicated due to prior auth or restrictive formularies.

The post-acute providers themselves also submitted many comments on the MA plan’s unwillingness to approve more than a few days at a time and then requiring the submission of onerous amounts of clinical information.

There were many comments from agents who sell Medicare supplements and MA plans complaining about a requirement that all calls with beneficiaries be recorded, describing the onerous cost and technical requirements this imposes upon them and worrying about the safety of beneficiary protected health information that may be revealed during the calls, although at the same time they expressed concerned about the “call centers” that inundate beneficiaries with calls and often sign them up without the person realizing they just gave up their traditional Medicare benefits.  

There were a surprising number of comments from New York City government retirees who are being forced into MA plans and are not happy about it. This is more an issue related to a decision by the city of New York rather than CMS so I am sure these will fall into the “We appreciate your comments but that is outside the scope of this request for information.”

But two comments stood out as my favorites. Coming in second place was an anonymous comment, possibly from a highly compensated executive of a MA plan, that stated simply “MEDICARE ADVANTAGE? Yes!”

But by far my #1 favorite comment came from someone who did not identify themselves but stated, in part, with much of the rest unpublishable, “Medicare Disadvantage was DESIGNED to suck original Medicare dry and eventually kill it, making it all private so every claim but your stupid ‘free gym membership’ gets denied.” I wonder how this commenter really feels.

It is worth pointing out that since this was simply a request for comment, we are unlikely to see CMS address any of the many criticisms of the MA plans anytime soon.

In the meantime, the Center for Medicare Advocacy has developed a great template for filing an official grievance with CMS about improper MA plan denials (found here). CMS does hold MA plans accountable for formal grievances and complaints that are submitted to 1-800-MEDICARE.

Encourage your patients to use those methods when applicable. You can also watch a recording of the American College of Physician Advisors town hall on best practices to address MA plan denials at this link.

Programming note: Listen every Monday morning when Dr. Hirsch makes his Monday Rounds on Monitor Mondays 10 Eastern and sponsored by R1-RCM.


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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