Radar on Medicare Advantage

After its last two reports suggested comprehensive reforms to Medicare Advantage plan reimbursement, the Medicare Payment Advisory Commission (MedPAC) in its June report to Congress shifted its MA focus to one area in particular: the potential for high-cost patient outlier data to skew the calculation of risk scores that determine MA plans’ risk-adjusted pay.

Although the Hierarchical Condition Category (HCC) risk adjustment model is intended to produce scores that reflect the relative health status of a plan’s enrollees, fee-for-service (FFS) Medicare spending data that is used to calculate risk scores can include a small group of outliers whose annual costs are much higher than the average costs of patients with a given condition, explained MedPAC Executive Director Jim Mathews during a June 15 web briefing with members of the press.

While the headline takeaway from the latest Medicare Trustees report was that the Hospital Insurance (HI) trust fund will be exhausted two years later than previously projected, industry experts suggest that the report should light a fire under Congress to take swift legislative action to sustain Medicare financing. During a recent webinar hosted by the Bipartisan Policy Center, a panel of seasoned policy experts agreed that the report underscored the need for comprehensive structural reform to the Medicare program, including potential changes to the way Medicare Advantage plans are paid.

Published on June 2, the Medicare Board of Trustees’ annual report provides previous and projected costs for the Medicare program’s two separate trust funds: the Hospital Insurance trust fund (HI), which helps pay for inpatient hospital and other services covered by Medicare Part A; and the Supplemental Medicare Insurance trust fund (SMI), which helps pay for physician, outpatient hospital, home health and other services covered by Parts B and D.

In CMS’s latest audit report, the agency confirms what an earlier AIS Health analysis of compliance notices indicated: the agency imposed approximately $1 million in civil money penalties (CMPs) based on 2021 referrals, and nearly half of that stemmed from one-third financial audit findings. CMS, meanwhile, cautioned the industry not to read too much into the latest audit results as they relate to 2020, when CMS audited a relatively small number of plans due to the COVID-19 public health emergency (PHE).

In the 2021 Part C and Part D Program Audit and Enforcement Report, published on June 7, CMS said it imposed 16 CMPs amounting to $1,043,953, or an average of $65,247 per CMP. Sponsors audited in 2021 covered 26% of enrollment.