Has your Medicare Advantage plan offered to provide you with an in-home health assessment? If so, it could be that they were more concerned with their bottom line than with the quality of your care.
Medicare Advantage plans used in-home health risk assessments and chart reviews to justify an estimated $7.5 billion in enhanced payments from the government in 2023, the U.S. Department of Health and Human Services’ Office of the Inspector General says in a recent report.
At that rate, the government is on track to shell out more than $1 trillion in additional payments over the course of the next decade, according to some estimates.
Health risk assessments and Medicare payments
Medicare beneficiaries can receive their benefits in two main ways: directly from the government (Original Medicare) or from a private insurance company that contracts with the government (Medicare Advantage plans).
To ensure equal access to Medicare Advantage plans for all patients, the government gives private insurers what are known as risk-adjusted payments when they enroll someone who has more health concerns. These higher payments are meant to help offset the higher costs that come with insuring someone who is not healthy.
However, some Medicare Advantage plans have apparently found a way to make enrollees look sicker than they are, a process known as upcoding.
With upcoding, the provider submits a billing code for a more serious (and more expensive) diagnosis based solely on information collected through a health risk assessment (HRA). These assessments may be done through an in-home visit or a review of a medical chart.
The Office of the Inspector General report noted that approximately 1.7 million Medicare Advantage enrollees had records showing this type of diagnosis but no other care related to the health condition. In a summary of the findings, the OIG states:
“The lack of any other followup visits, procedures, tests, or supplies for these diagnoses … raises concerns that either: (1) the diagnoses are inaccurate and thus the payments are improper or (2) enrollees did not receive needed care for serious conditions reported only on HRAs or HRA-linked chart reviews.”
By entering diagnoses through a health risk assessment, insurers may be able to pocket the increased risk-adjusted payments without actually incurring any additional costs for patient care.
The OIG made three recommendations to combat the potential misuse of health risk assessments. They include:
- Imposing restrictions on their use
- Conducting audits to validate a diagnosis
- Determining whether certain health conditions are most vulnerable to misuse by Medicare Advantage providers
Of these, the Centers for Medicare & Medicaid Services — the division of the Department of Health and Human Services that runs the Medicare program — concurred with only the third suggestion.
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