RISE summarizes the latest headlines that impact Medicare, Medicare Advantage, and Medicaid.
Trump signs executive orders on preexisting conditions, surprise billing but unclear how it will be enforced
President Donald Trump on Thursday signed an executive order that he said would protect Americans who have preexisting conditions from insurance discrimination even as he continues to advocate that the Supreme Court rule the Affordable Care Act (ACA) unconstitutional, including the law’s popular mandate that protects people with preexisting conditions. The high court is expected to take up the ACA case on Nov. 10, a week after the presidential election. Trump has yet to offer a plan that would replace the ACA but also announced he signed an executive order to ban surprise medical bill. Both orders direct Congress to work out the details.
OIG official weighs in on recent MA investigations
Christi A. Grimm, principal deputy inspector general of the HHS Office of Inspector General writes in a piece for Healthcare Dive that Medicare Advantage (MA) plans must ensure practices drive better care, not higher profits, and enact policies and procedures that ensure the integrity and usefulness of the data. She warned that her office is monitoring potential abuse of risk adjustment, citing a December report that found MA plans paid billions a year for diagnosis unrelated to any clinical services. That controversial report, however, was flawed, according to Sean Creighton, who chairs the RISE Risk Adjustment Policy Advisory Committee. The OIG also recently released a report on completeness of health risk assessments (HRAs) payment data, validity of diagnoses, and quality of care coordination for beneficiaries. “My office and other government agencies are targeting oversight to make sure plans do not pad risk adjustments with unsupported diagnoses,” Grimm wrote. “When plans find new real diagnoses, the plans deserve the extra payment, but only if patients get appropriate care.”
OIG releases report on MA overpayments due to incorrect acute stroke diagnosis codes
This month the OIG also released a report that found almost all of the selected acute stroke diagnosis codes that physicians submitted under traditional Medicare and that the Centers for Medicare & Medicaid Services (CMS) used to pay MA organizations in 2015 or 2016 for transferred enrollees did not comply with federal requirements and the medical records did not support the diagnosis codes. As a result, CMS made inaccurate payments of more than $14.4 million to MA organizations. CMS agreed with the OIG recommendation that it would continue to educate physicians on the correct submission of codes and would review existing policies and procedure to evaluate whether additional clarification is needed.
CMS issues warning about drop in children medical care, vaccinations due to COVID
CMS this week released preliminary Medicaid and Children’s Health Insurance Program (CHIP) data that shows rates for vaccinations, primary, and preventive services among children have dropped significantly during the COVID-19 public health emergency. The decline may have significant impact on long-term health outcomes for children. CMS hopes the preliminary data will serve as a warning and raise awareness of the services Medicaid and CHIP provides. “As a mother, I have witnessed first-hand how important early and regular access to screening and medical care is for children’s development,” CMS Administrator Seema Verma said in the announcement. “The absence of these vital health care services may have lifelong consequences for these vulnerable children, and I call on states, pediatric providers, families, and schools to ensure children catch-up on overdue medical, behavioral health and dental appointments as well as childhood immunizations.”