Radar on Medicare Advantage

For the fifth year in a row, BlueCross BlueShield of Tennessee (BCBST) recently celebrated the achievements of hundreds of high-performing primary care physicians in its PPO network. The provider engagement effort is part of an enterprise-wide initiative that has helped the insurer maintain a 4-star rating from CMS for its Medicare Advantage PPO plan while observing continued population-level improvement on key quality metrics, including patient experience measures that will soon receive an increased weighting in the CMS star ratings program.

In an Aug. 17 press release, the insurer named 43 providers and practices across the state who earned a 4.5 out of 5 star rating in BCBST’s Medicare Advantage 2019 Quality+ Partnerships Program. One of them, Charles A. Ross, M.D., of Kingsport, earned a 5-star rating. Many more physicians and practices were recognized on the insurer’s website for achieving a rating of 4 stars or higher. BCBST serves approximately 157,000 MA enrollees overall, including 138,000 lives in its PPO plans.

As the COVID-19 pandemic continues to shake up the health care system — and disproportionately impact vulnerable patients such as dual eligibles enrolled in Medicare-Medicaid Plans (MMPs) or Special Needs Plans (SNPs) — the Association for Community Affiliated Plans (ACAP) is calling on CMS to extend a multitude of flexibilities that will allow such plans to access the resources they need to continue serving at-risk members.

These plans “are bearing the brunt of the pandemic specifically because their enrollees are more at risk,” wrote ACAP CEO Margaret Murray in a Sept. 3 letter to Center for Medicare Principal Deputy Administrator and Director Demetrios Kouzoukas. ACAP’s not-for-profit health plans collectively provide coverage to 20 million Medicaid, CHIP, dual-eligible and exchange enrollees, and they enroll more than one-third of the total MMP membership nationwide. “Overall, we are asking CMS to hold MMPs and SNP harmless to mitigate the effects of COVID-19 on plan operations,” she wrote, adding that how some changes are applied may vary by geographic region.

In a surprise move aimed at giving some clarity to Medicare Advantage and Part D plans already thinking about their 2022 plan bids, CMS on Sept. 14 released Part 1 of the 2022 Advance Notice. But the items in the notice were largely expected — including the final phaseout of legacy Risk Adjustment Processing System (RAPS) data in determining risk scores — and key information is still forthcoming.

CMS since 2018 has issued the Advance Notice of Methodological Changes for MA Capitation Rates and Part D Payment Policies in two parts, thanks to a requirement in the 21st Century Cures Act (signed into law in 2016) that any proposed changes to the CMS Hierarchical Condition Category (HCC) risk adjustment model have a 60-day comment period. The agency for 2021 posted the first document in January of this year (RMA 1/16/20, p. 1) and for 2020 issued it in late December.

In a development that has some actuaries scratching their heads, the U.S. Attorney’s Office for the Eastern District of Pennsylvania on Sept. 3 unveiled a settlement with two Medicare Advantage plan subsidiaries of Independence Blue Cross (IBC) involving “inflated” MA plan bids. But the case did not have to do with allegations of exaggerated risk scores, which have been central to many recent MA false claims cases and attracted the attention of the Dept. of Justice (DOJ), and instead centers on standard bid miscalculations that might have been ignored — had it perhaps not been for the insurer’s complicated history with the whistleblower.

The two subsidiaries of the Philadelphia-based insurer — Keystone Health Plan East, Inc. (KHPE) and QCC Insurance Company, Inc. — will pay $2.25 million plus interest to resolve False Claims Act allegations of “incorrectly calculating anticipated plan costs, resulting in inflated Medicare Advantage plan bids” to CMS, according to the press release from the U.S. Attorney’s Office. The settlement resolves a lawsuit initially filed by IBC employee Eric Johnson, in which the federal government intervened. The case, United States ex rel. Eric Johnson v. Independence Blue Cross (No. 10-CV-1520), at press time remained under seal. Johnson’s share of the recovery is approximately $500,000.