HHS Watchdog accuses CVS Medicare advantage coding up

Diving brief:

• A Medicare Advantage Plan managed by CVS has inflated diagnostics for its members between 2018 and 2019, which led to almost 7 million dollars in an overpayed estimated, according to a new audit of the Inspector General’s HHS office.
• Last week, the HHS OIG published an audit of Coventry Health and Life Insurance Company which found the vast majority of the diagnoses that Coventry submitted to the CMS to justify the health needs of its members was not supported by the medical records of real suppliers.
• The regulators recommended Coventry to seek other cases of non-compliance after the audit period and to reimburse the $ 7 million, as well as the additional excessive that it is able to identify. Coventry, who was widely disagreed with the audit conclusions, refused.

Diving insight:

The majority of Medicare beneficiaries are now registered with Medicare Advantage plans, in which private payers receive a monthly lump sum of the CMS to manage their care. This reimbursement is adjusted according to the health needs of the registrants, so that insurers are paid more for more sick members. The government follows the health of registrants thanks to the diagnostic codes collected by their insurer MA.

The purpose of this arrangement was to encourage insurers to control health care costs for the elderly in health insurance, to save government money while improving primary care upstream. This inadvertently led to a practice entitled Upcoding, in which insurers exert the health risks of their members to artificially inflate their reimbursement.

Upcoding is a serious problem. According to the Congressional Advisory Group, the MA plans should see an increase in payment of 10% compared to traditional health insurance due to the upward coding, according to the Congressal Advisory Group. During the next decade, Codoscopte could lead to MA of ME of Medicare out of $ 600 billion, according to a committee for a federal budgetary analysis responsible for Medpac results.

Coventry’s audit by the HHS OIG is the last of a series of exams verifying the accuracy of the diagnostic codes that organizations submit to the CMS. The audit, which took place from July 2022 to October, identified diagnostics with a higher risk of being broken down and grouping them into specific categories, such as an acute stroke, sepsis or prostate cancer.

He found that most of the medical records provided by Coventry did not support diagnostic codes, and that, in many cases, Coventry could not find any documentation of the patient’s verification.

“Coventry’s policies and procedures to prevent, detect and correct non-compliance with the requirements of the CMS program, such as mandated by federal regulations, could be improved,” said Hhs Oig in its report. “Based on our sample results, we estimated that Coventry received at least $ 6,995,522 in net overpayed For 2018 and 2019 “- approximately 0.2% of the total reimbursement of $ 3.5 billion that Coventry received from the government during this period.

In response, Coventry, based in St. Louis, said that the government’s audit methodology was biased because it focused on the diagnostic codes which were at high risk of causing overpayments instead of looking for the coding of its entire population, in which the conditions could be exaggerated for certain patients but undergraded for others.

“We believe Oig The draft report deviates from clear and opposite advice from Medicare – including from Goard himself – and contribute To the false impression that the plans of my play the system, ”wrote Patrick Jeswald, director of CVS compliance for Medicare, in a letter to the agency.

“We have critically examined our risk adjustment programs and our supplier contracts and will continue to do so. However, despite all these works, it will never be possible to ensure that the thousands of providers serving the members of my will code the millions of bids with precision each time,” added Jeswald.

CVS has not agreed to reimburse the estimated overpayments, claiming that the estimate of $ 7 million in HHS OIG was defective and that OIG has no statutory authority to request a refund.

Coventry covers nearly 200,000 my registered.

Upcoding is not unique to CVs. The HHS OIG has carried out more than twenty of these audits, most of them finding the majority of the diagnostic codes submitted by the organizations of MA are not supported by evidence – including the plans managed by Humana, Cigna, Centene and other insurance companies.

Although the election of President Donald Trump was considered a net positive for the massive control industry, the best health regulators in his administration have been more open to the reprimand of practices such as the codoscopte than much planned.

The CMS administrator, Mehmet Oz, who supported the plans of MA in the past, said during his confirmation hearings that he planned to strongly scrutinize the private medication plans – a promise of Oz followed last month when the CMS announced that he planned to progress the audits of Trop.

Congress Republicans have also said that they plan to target fraud, waste and abuse in health insurance in their massive reconciliation bill under examination by the Senate. However, some leadership members have resumed their previous comments, concerned about the political return to reach the massive federal insurance program after influential payers lobbies argued that any reform of coding practices would be an attack on Medicare’s elders.