RISE reviews the latest headlines, including the Office of Inspector General (OIG) reports, trending telehealth diagnoses, and the introduction of a new bill to improve the oversight of nursing homes.


CVS discloses OIG auditing Aetna’s MA program

CVS Health, the parent company of Aetna’s Medicare Advantage (MA) business, disclosed in a recent 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. The Centers for Medicare & Medicaid Services (CMS) will reimburse an MA plan at a higher rate for caring for sicker patients or those with a more severe diagnosis and higher risk score.

Earlier this year an OIG audit found that CMS overpaid a Humana Inc. health plan for seniors in Florida by nearly $200 million in 2015 by overstating how sick some patients were. The OIG reportedly is planning to release similar audits within the next two years. In the filing, CVS said it expects CMS and the OIG to continue the audits and that CMS may require Aetna to refund risk-adjusted premiums if they aren’t supported by medical record data.

The CVS disclosure was made in the wake of the Justice Department’s announcement that it had joined lawsuits filed by 10 whistleblowers alleging that members of the Kaiser Permanente consortium violated the False Claims Act by submitting inaccurate diagnosis codes for its MA plan enrollees in order to receive higher reimbursements.

OIG: Medicare continues to make overpayments for chronic care management services

A new OIG report has found that overpayments for chronic care management (CCM) services has cost the program and its beneficiaries millions of dollars. The audit covered more than 7.8 million claims submitted by physicians and over 240,000 claims submitted by hospitals for noncomplex and complex CCM services provided in calendar years 2017 and 2018. Medicare paid $356 million for those services.

The OIG found that Medicare made $1.9 million in overpayments associated with 50,192 claims for noncomplex and complex CCM services that didn’t comply with federal requirements. For these claims, beneficiaries’ cost sharing totaled $540,680. Specifically, the OIG found:

  • $1.4 million in overpayments associated with 38,447 claims for instances in which providers billed noncomplex or complex CCM services more than once for the same beneficiary for the same service period
  • $438,262 in overpayments identified in 10,882 claims for instances in which the same provider billed for both noncomplex or complex CCM services and overlapping care management services rendered to the same beneficiaries for the same service periods
  • $52,086 in overpayments identified in 863 claims for incremental complex CCM services that were billed along with complex CCM services

The OIG said the errors occurred because CMS did not have claim system edits to prevent and detect overpayments. CMS has agreed with the OIG’s recommendation that the agency direct the Medicare contractors to recover the $1.9 million for claims that are within the reopening period and instruct providers to refund up to $540,680, which beneficiaries were required to pay. The OIG also recommended that CMS notify appropriate providers to exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation. Finally, the OIG suggested that CMS implement claim system edits to prevent and detect overpayments for noncomplex and complex CCM services.

Fair Health: The top 5 national telehealth diagnoses in May

The latest data from Fair Health’s monthly telehealth regional tracker indicated substance use disorders joined the top five telehealth diagnoses nationally for the first time in May, in fifth place. Substance use disorders also remained in the top five in the Midwest and Northeast, as had been the case in April. The pattern was consistent with reports of increased misuse of opioids and stimulants during the COVID-19 pandemic.

Fair Health reported that the percentage of telehealth claim lines accounted for by mental health conditions rose nationally and in every region in May 2021. Mental health conditions remained in the number one spot among telehealth diagnoses nationally and in every region. The other diagnoses that earned spots on the top five list included developmental disorders, acute respiratory diseases and infections, and joint/soft tissue diseases and issues.

Nursing home bill would increase staffing, improve infection control and inspections

Senior Democratic senators this week introduced a bill to improve the quality of care and oversight of nursing homes. The Nursing Home Improvement and Accountability Act would require nursing homes to meet minimum staffing standards, ensure a Registered Nurse (RN) is available 24 hours a day, require a full-time infection control and prevention specialist, and provide additional resources through Medicaid to support these care and staffing improvements and raise wages. The bill also includes steps to increase transparency and accountability by improving data collection, providing better information to residents and their families, and enhancing the effectiveness of state surveys. It was introduced by Senate Finance Committee Chairman Ron Wyden, D-Ore., Senate Aging Committee Chairman Bob Casey, D-Pa., along with Senators Richard Blumenthal, D-Conn., Michael Bennet, D-Colo., Sheldon Whitehouse, D-R.I., and Sherrod Brown, D-Ohio. Mark Parkinson, president and CEO of the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), said in a statement that although the association appreciates some of the steps outlined in the bill, the profession needs more to adequately serve long-term care residents. He also expressed opposition to the proposed restrictions on arbitration agreements. Furthermore, he said, “the proposal to institute permanent minimum staffing requirements without a permanent funding source would be incredibly challenging for long-term care providers. Providers will not be able to meet staffing requirements if we can’t find people to fill the open positions. There must be a comprehensive approach to staffing beyond just numbers.”