As we head into 2022, here’s a look back at our most viewed articles of 2021. Trending topics included fraud lawsuits, Star ratings, and federal investigations into overpayments.
1. Justice Department joins MA fraud lawsuit against Kaiser Permanente
Topping the list of our most-read articles was news that the government intervened in False Claims Act lawsuits against Kaiser Permanente affiliates for submitting inaccurate diagnosis codes for risk-adjusted payments to the Medicare Advantage program. The complaints claim that Kaiser pressured its physicians to add diagnoses to patient medical records often months or a year after the patient encounter to raise patient risk scores. The patients did not actually have the diagnoses, or they weren’t considered or addressed during the outpatient encounter, the whistleblower lawsuits allege.
2. CMS releases 2022 MA and Part D Star ratings
The Centers for Medicare & Medicaid Services in October released historic Star ratings ahead of Medicare open enrollment for Medicare Advantage and Medicare Part D (MA-PD) prescription drug plans. Seventy-four Medicare Advantage plans received the highest rating of 5 stars and 68 percent of MA-PD plans earned 4+ Stars.
3. CMS Star Ratings alert: Two highly-weighted HOS measures removed from 2022 and 2023 calculations due to COVID-19
In an August 5 memo to all Medicare Advantage plans, the agency announced that the COVID-19 public health emergency significantly impacted the validity of measures related to physical and mental health currently used in the Star Ratings.
4. OIG: 20 MA plans used questionable billing practices to maximize risk adjustment payments
A September Office of Inspector General report found that 20 of 162 Medicare Advantage companies studied drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and health risk assessments and on no other service records.
5. OIG estimates UPMC received $6.4M in overpayments for high-risk diagnoses
The following month the Office of Inspector General released its audit of UPMC Health Plan, Inc., which it conducted to determine whether the Medicare Advantage organization appropriately submitted selected diagnoses codes to the Centers for Medicare & Medicaid Services’ (CMS) risk adjustment program. According to the report, most of the selected diagnoses codes that UPMC submitted to CMS for the agency’s risk adjustment program did not comply with federal requirements.
6. UnitedHealth loses appeal over MA overpayments
A U.S. appeals court in August ruled against UnitedHealthcare and overturned a 2018 district court decision that had vacated the Center for Medicare & Medicaid Services’ Medicare Advantage Overpayment Rule. UnitedHealth had scored a major win in 2018 when a federal judge determined that the MA overpayment rule was not equitable to Medicare and MA insurers. But the U.S. States Court of Appeals for the District of Columbia Circuit reversed the district court decision and ruled that the overpayment rule doesn’t violate Medicare statute’s “actuarial equivalence” and “same methodology” requirements and is not arbitrary and capricious as an unexplained departure from prior policy.
7. OIG audit targets Aetna MA program
CVS Health, the parent company of Aetna’s Medicare Advantage (MA) business, disclosed in a federal filing that the U.S. Department of Health and Human Services’ OIG is auditing MA operations. The OIG has been conducting a series of audits to make sure MA plans aren’t submitting inaccurate diagnosis codes for risk-adjustment payments.
8. Ezekiel Emanuel on the Biden administration’s health care priorities and the need for the industry to invest in primary care, digital innovation
Last year’s RISE National Keynote Ezekiel J. Emanuel, M.D., discussed the current health care landscape prior to the annual conference. Emanual, a health care policy expert, was the former advisor to President Joe Biden’s transition team on COVID-19. He talked with RISE about the Biden administration’s health care priorities, the Medicare Trust Fund, primary care, and digital innovation.
9. CMS mandates COVID-19 vaccinations for staff at all Medicare, Medicaid-certified facilities
In September, the Centers for Medicare & Medicaid Services (CMS), in collaboration with the Centers for Disease Control and Prevention (CDC), announced that emergency regulations requiring vaccinations for nursing home workers will be expanded to include hospitals, dialysis facilities, ambulatory surgical settings, and home health agencies, among others, as a condition for participating in the Medicare and Medicaid programs. Due to legal challenges to the rule, CMS has since issued a memo to suspend enforcement of the mandate.
1o. How one health plan improved member engagement, Stars, and quality performance by addressing SDoH
Representatives from UnitedHealthcare, a health insurance plan with benefit programs for individuals and families, employers, and Medicare and Medicaid beneficiaries, explained how they leveraged social determinants of health programs to better meet member needs, improve Star ratings, and close quality and HEDIS® gaps.