Radar on Medicare Advantage

The risk adjustment system used to pay Medicare Advantage plans continues to face intensifying scrutiny from the federal government, with the Dept. of Justice (DOJ) intervening in multiple False Claims Act (FCA) complaints and the HHS Office of Inspector General focusing on retrospective chart reviews and high-risk diagnosis codes. Now, attorneys say health care providers should be on high alert as well. While prior DOJ complaints-in-intervention have focused largely on MAOs conducting “one-way” chart reviews, more recent lawsuits focus on the use of “addenda” — information retroactively added to a patient’s medical record — which one law firm says indicates a new area of scrutiny.

CMS’s reinterpretation of “primarily health-related” benefits has led to more Medicare Advantage plans offering services such as in-home support services, home-based palliative care, support for caregivers and therapeutic massage for the upcoming plan year, according to a new analysis from Milliman. The number of MA plans that will offer one of five selected benefits grew 43% from 2021, to 824 plans, while 202 plans will offer at least two of the benefits next year, up from 175 plans in 2021. Notably, the number of plans offering in-home support skyrocketed from 296 in 2021 to more than 500 in 2022. Of the five studied benefits, only adult day health services will see a decline in availability next year.

Continuing a series of audits in which the HHS Office of Inspector General is reviewing the accuracy of diagnosis codes submitted to CMS by Medicare Advantage organizations, OIG last month said most of the codes it reviewed for UPMC Health Plan, Inc. could not be validated by medical records. The agency used its own extrapolation methodology to estimate that the Pittsburgh-based insurer owes $6.4 million for the 2015 and 2016 payment years, prompting a detailed rebuttal from UPMC and adding to the ongoing debate over the use of sampling to approximate a plan’s true payment error rate.

With several states issuing requests for proposals (RFPs), 2022 is shaping up to be a solid year for payers pursuing new Medicaid contract awards. Iowa is looking for up to four MCOs to serve Iowa Health Link, up from its current two, and Tennessee’s awards could come by year-end. As for the most hotly competitive RFPs, eyes will be on California and Texas as they prepare to begin the procurement process for contracts that will cover about 3.5 million and 4.3 million lives, respectively. Meanwhile, previous contract awards in Kentucky, Louisiana and the District of Columbia have caused considerable controversy and sparked ongoing legal challenges between payers and state Medicaid officials, prompting rebids. Below, see an overview of key RFPs that are expected to be issued or awarded in the coming months.

Providing its first glimpse of earnings for 2022, UnitedHealth Group at its Nov. 30 Investor Conference said it expects to achieve revenue in the range of $317 billion to $320 billion and adjusted net earnings per share (EPS) of $21.10 to $21.60. Its UnitedHealthcare division is expected to contribute $245.5 billion to $247.5 billion, driven in part by the anticipated addition of 600,000 to 650,000 net new Medicare Advantage members, reflecting year-over-year growth of 9% to 10%.