Federal investigators are concerned Medicare Advantage organizations may be using chart reviews to inappropriately inflate their risk-adjustment payments, according to a report released by the Office of Inspector General.
The news isn't a surprise to CMS. Federal officials know some Medicare Advantage insurers are overcharging the government through elevated risk scores that exaggerate how sick patients are. While CMS officials have routinely postponed or taken the brakes off efforts to collect the money, they are again attempting to recoup payments.
Currently, Medicare Advantage organizations use chart reviews to improve the accuracy of payments made through CMS' risk-adjustment program. The risk-adjustment program ensures Medicare Advantage organizations that cover sicker and costlier members are still incentivized to participate in the program. The chart reviews allow Medicare Advantage organizations to edit diagnoses in encounter data after a patient's record is reviewed to better reflect their care.
But OIG said some Medicare Advantage organizations can use the chart reviews, especially ones that aren't linked to patient records, to circumvent CMS' requirement that only face-to-face medical visits are eligible for risk adjustment. This leads to improperly inflated risk-adjustment payments, OIG said.
After analyzing encounter data, OIG found 99 percent of chart reviews added diagnoses instead of deleting them. Inspectors also found diagnoses that the organizations reported only on chart reviews, and not on service records, led to about $6.7 billion in payments for 2017. OIG said CMS based about $2.7 billion in risk-adjusted payments on chart review diagnoses that weren't linked to a specific service or a face-to-face visit.
"These findings raise three types of potential concerns," OIG said. "First, there may be a data integrity concern that MAOs are not submitting all service records as required. Second, there may be a payment integrity concern if diagnoses are inaccurate or unsupported — making the associated risk-adjusted payments inappropriate. Third, there may be a quality-of-care concern that beneficiaries are not receiving needed services for potentially serious diagnoses listed on chart reviews, but with no service records."
OIG recommended that CMS improve its oversight of risk-adjusted payments to Medicare Advantage organizations, audit chart reviews and reassess the chart review system. CMS agreed with the findings.