RISE summarizes the latest regulatory headlines.

OIG: Tufts Health Plan owes feds $3.7M in overpayments for high-risk diagnosis codes

A recent Office of Inspector General (OIG) Medicare Advantage compliance audit estimates that Tufts Health Plan received at least $3.7 million in overpayments for high-risk diagnosis codes in 2015 and 2016.

The audit focused on seven groups of high-risk diagnosis codes to determine whether the codes that Tufts submitted to CMS for the agency’s risk adjustment program complied with federal requirements.

OIG said it sampled 212 unique enrollee-years with the high-risk diagnosis codes for which Tufts received higher payments for 2015 through 2016. The review focused on the portions of the payments that were associated with the high-risk diagnosis codes, which totaled close to $750,000.

According to OIG, most of the selected diagnosis codes that Tufts submitted to the Centers for Medicare & Medicaid Services (CMS) were not supported in the medical record. Based on the sample results, OIG estimated that Tufts received at least $3.7 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.

The watchdog recommends that Tufts refund the federal government the $3.7 million, identify similar instances of noncompliance that occurred before or after the audit period and refund any other overpayments, and continue to improve its existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes that are at high risk for being miscoded comply with federal requirements (when submitted to CMS for use in its risk adjustment program) and take the necessary steps to enhance those procedures.

However, Tufts disagreed with the findings and recommendations and said that the report reflected misunderstandings of legal and regulatory requirements underlying the MA program.

According to Tufts, the OIG should not have included the errors associated with five enrollee-years in its calculation of total net overpayments because had already submitted corrections to CMS. Although the health plan did not specifically comment on the errors associated with the other 154 enrollee-years, it disagreed with the OIG sampling and review methodologies.

OIG said its findings and recommendations are valid, however, it revised its findings for the five enrollee-years and considered the impact of the budget sequestration reduction. As a result, it reduced its first recommendation from $4 million to $3.7 million for the final report and revised the beginning of its third recommendation in recognition of Tuft’s past efforts to improve its compliance program.

Justice Department files suit to stop UnitedHealth’s $13B buy out of Change Healthcare

The Department of Justice has filed a civil lawsuit to stop UnitedHealth Group Incorporated from acquiring Change Healthcare Inc. The complaint, filed in the U.S. District Court for the District of Columbia, alleges that the proposed $13 billion transaction would harm competition in commercial health insurance markets, as well as in the market for a vital technology used by health insurers to process health insurance claims and reduce health care costs.

“Quality health insurance should be accessible to all Americans,” Attorney General Merrick B. Garland said in the announcement. “If America’s largest health insurer is permitted to acquire a major rival for critical health care claims technologies, it will undermine competition for health insurance and stifle innovation in the employer health insurance markets. The Justice Department is committed to challenging anticompetitive mergers, particularly those at the intersection of health care and data.”

The Justice Department alleges the proposed transaction would give United access to a vast amount of its rival health insurers’ competitively sensitive information. Post-acquisition, United would be able to use its rivals’ information to gain an unfair advantage and harm competition in health insurance markets. The proposed transaction also would eliminate United’s only major rival for first pass claims editing technology—a critical product used to efficiently process health insurance claims and save health insurers billions of dollars each year—and give United a monopoly share in the market.

Change Healthcare provides health insurers with vital software and services, including electronic data interchange (EDI) clearinghouse services, which transmit claims and payment information between insurers and providers, and first-pass claims editing solutions, which review claims under the health insurer’s policies and relevant treatment protocols. United’s acquisition, the Justice Department said, would allow United to tilt the playing field in its favor, harming current competition and allowing United to control and distort the future course of innovation in the health care industry.

CMS revamps ACO model to advance health equity, improve care of Medicare beneficiaries

The Centers for Medicare & Medicaid Services (CMS) has launched a redesigned Accountable Care Organization model that it says better reflects its vision to achieve equitable outcomes through high-quality, affordable, person-centered care. The new model, ACO Realizing Equity, Access, and Community Health (REACH) Model, is a revamp of the Global and Professional Direct Contracting (GPDC) Model. In addition, the agency says it is canceling the Geographic Direct Contracting Model immediately.

The ACO REACH Model builds on the agency’s 10 years of experience with accountable care initiatives, such as the Medicare Shared Savings Program, the Pioneer ACO Model, and the Next Generation ACO Model. CMS said the revised model provides novel tools and resources for health care providers to work together more closely to improve the quality of care for people with Traditional Medicare. To help advance health equity, the ACO REACH Model will require all participating ACOs to have a robust plan describing how they will meet the needs of people with Traditional Medicare in underserved communities and make measurable changes to address health disparities. Additionally, under the ACO REACH Model, CMS will use an innovative payment approach to better support care delivery and coordination for people in underserved communities.

REACH ACOs will be responsible for helping all different types of health care providers—including primary and specialty care physicians—work together, so people get the care they need when they need it. In addition, people with Traditional Medicare who receive care through a REACH ACO may have greater access to enhanced benefits, such as telehealth visits, home care after leaving the hospital, and help with co-pays. They can expect the support of the REACH ACO to help them navigate an often complex health system. The first performance year of the redesigned ACO REACH Model will start on January 1, 2023, and the model performance period will run through 2026.

HHS: 40% drop in uninsured rate among Blacks since ACA implementation

The Department of Health and Human Services (HHS) released a new report that shows historic gains in health care coverage access and affordability among Black Americans.

The report, which was produced by researchers in HHS's Office of the Assistant Secretary for Planning and Evaluation (ASPE), finds that since the implementation of the Affordable Care Act, the uninsured rate among Black Americans under age 65 decreased from 20 percent in 2011 (approximately 7.1 million people) to 12 percent in 2019 (approximately 4.4 million people), a decline of 40 percent. It also notes the White House administration’s actions over the year to expand affordable coverage options through American Rescue Plan subsidies, a Marketplace Special Enrollment Period) and enhanced outreach to Black Americans.

The issue brief shows that states that have not expanded Medicaid have the highest percentage of uninsured adults and children who are Black. If the remaining 12 non-expansion states (Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, Wyoming) were to expand Medicaid, an estimated 957,000 Black Americans without insurance coverage would become eligible for Medicaid coverage.

Other findings from the report reveal:

  • Since the implementation of the ACA’s coverage provisions, the uninsured rate among Black Americans under age 65 decreased by eight percentage points, from 20 percent in 2011 (approximately 7.1 million people) to 12 percent in 2019 (approximately 4.4 million people). The uninsured rate for Black Americans, however, is still higher than that for white Americans: 12 percent compared to 9 percent.
  • The uninsured rate among Black Americans that report Latino ethnicity is similar to the uninsured rate among non-Latino Black Americans.
  • Southern states that have not expanded Medicaid have some of the nation’s highest uninsured rates for all population groups, as well as large Black populations.
  • While access to care improved for Black Americans between 2011 and 2020, disparities in affordability of health care between Black and white Americans persist.
  • Under the American Rescue Plan, which increased Marketplace subsidies, 76 percent of uninsured Black Americans could find a plan for less than $50 a month, and 66 percent could find a plan for $0 a month in 2021.