On Thursday, a senior official from the Centers for Medicare and Medicaid questioned the future of Medicare Advantage payments, citing research from government observers and experts.
Office of the Inspector General of the Department of Health and Human Services proposed Medicare Advantage plans can show their beneficiaries worse than they really are in order to maximize benefits from the federal government.
“We are also very concerned about the general trends in code growth in the MA program versus the general fee program,” said Jonathan Blum, CMS chief deputy administrator, at an event in Washington DC on Thursday.
The OIG report says MA’s plans “may have misused” chart reviews and health risk assessments to maximize government benefits. OIG found that 20 of MA’s 162 companies attracted a disproportionate share of $ 9.2 billion in payments for diagnoses reported only in card reviews and health risk assessments and not in any other service records. These evaluations are usually carried out by the health plan or providers hired by the health plan, OIG says.
Download the Modern Healthcare app to stay on top of industry news.
“We are looking at the same data as the supervisory community and are thinking carefully about how we will respond to this,” Blum said, adding that CMS is considering regulation.
As the number of Medicare Advantage enrollments grows, the government will need to consider whether to change the way the federal government pays for these plans, he said.
The percentage of Medicare recipients in private plans is expected to reach 50% by 2030.
According to a report released this summer, in 2021, Medicare’s total payments to MA plans were about 104% of traditional service costs. Medicare Payment Advisory Board…
Plans are paid based on the average Medicare spends on services for members in specific geographic regions.
MedPAC recommended to Congress that this calculation, called the benchmark, be changed to achieve greater savings for Medicare.
“Should we use a benchmark? Should we try something else in the future for risk adjustment purposes and for the general purpose of the benchmark? ” said Blum.
“This is going to be one of the most difficult technical issues that come up with advancing Medicare.”
MA plans receive discounts on offering value-added services to beneficiaries, such as gym membership and vision care, when they bid below this benchmark.
“We need to ask ourselves what drives the opportunity for additional benefits and cost savings for private plans, and think about payment policies to ensure they are fair not only for the beneficiaries in the plan, but for the entire program,” he said.