Medicare Advantage: Double standards need not apply

AHIP President Matt Eyles recently issued a press release condemning the new final rule from CMS regarding the Risk Adjustment Data Validation for Medicare Advantage (MA) plans, which includes requirements that MA organizations provide medical record documentation that support diagnoses for risk adjustment payments.

Calling the plan “fatally flawed and unlawful,” he claimed that the program will raise premiums, hurt seniors, and reduce health equity by reducing benefits and options for MA plans.

As a physician, I have been required to produce adequate documentation to CMS for every Medicare patient visit when requested, leading me to question why MA organizations should be exempt from the same requirement.

Recently, a large insurance carrier was sued for unsubstantiated elevation of Risk Adjustment Factor (RAF) scores for their MA patients. And most large insurers in the program have already settled or are facing federal fraud lawsuits. It appears the insurance industry wants to be held to a different standard than the providers that deliver the care. If the American taxpayer is footing the bill for MA plans, then CMS has the right to assure that patients are receiving the care that they deserve––and that taxpayers are paying for.

It seems that what the insurance industry is saying is, “Just trust us to do the right thing.” Honestly, however, too many have already demonstrated such trust might be misplaced. 

Where’s the Accountability?

It all boils down to accountability. Physicians and provider organizations have always been accountable––since the advent of Medicare and before Medicare Advantage. When a bill is submitted to Medicare, documentation is submitted to back up that bill. Without documentation, or a note, there are repercussions—denials, fines, and more.

Now, it seems, we’ve entered a new era of prospective payment to cover all. There are accountability rules built into the system: the MEAT Protocol––Manage, Evaluate, Assess, and Treat. This has been well-known since the launch of Medicare Advantage.

Medicare eventually realized that it was spending more money caring for MA patients than for traditional Medicare enrollees. And the government wondered why because this was not the way the program was designed. MA was supposed to be more patient-driven, and focused, to improve patient outcomes, and deliver the biggest bang for the buck.

Well, the government is paying more bucks, but not getting more bang. And once officials realized that they tried to figure out how this happened. What they discovered were a whole lot of incidences of upcoding; specifically, the assignment of Hierarchical Condition Coding (HCC) diagnosis codes for which there were no supporting documentation.

Government Takes Note…and Action

To reclaim some of the overpayments, regulators are implementing rules to lower payments to insurers by billions of dollars a year, but these changes will be phased in over three years. Meanwhile, the Biden administration has finalized a new rule to cut down on overbilling, with a program that would examine claims back to 2018. The amount owed for 2018 alone has been estimated at $479 million.

Now, Senators Bill Cassidy (R-LA) and Jeff Merkley (D-OR) have introduced new legislation aimed at reducing excessive payments to MA plans by implementing modifications to MA risk adjustment. The No Unreasonable Payments, Coding, or Diagnoses for the Elderly (No UPCODE) Act intends to achieve this by enhancing the methods MA plans use to evaluate patients' health risks. If the bill is enacted, the senators anticipate it will save taxpayers billions of dollars by removing incentives for overbilling care.

Double Standards

The fact that plans are being audited back to 2018 indicates that the government knows this practice has been going on for as long as MA has been in operation. And now, the insurance industry doesn't want to be held accountable. They claim it will reduce care and increase premiums for members.

But, at the end of the day, the practice is still fraud. And there cannot be two standards for the two types of Medicare. If traditional fee-for-service Medicare must adhere to the documentation requirements, then so should MA.

Jay Anders, M.D. is the chief medical officer of Medicomp Systems, which provides physician-driven, point-of-care solutions that fix EHRs.