RISE summarizes recent regulatory-related headlines and reports.
OIG will add high-risk diagnosis codes to the work plan
The Office of Inspector General (OIG) announced it will add an audit of diagnosis codes that Medicare Advantage organizations submit to the Centers for Medicare & Medicaid Services (CMS) as part of the Medicare Part C Risk Adjustment Program to its annual work plan. The audit results are expected to be published in 2026.
OIG said the audit will focus on diagnoses that are at high risk for not being supported by medical records for a face-to-face encounter with an acceptable provider type and resulted in increased risk-adjusted payments from CMS to Medicare Advantage organizations. The research will determine whether the Medicare Advantage organization’s submission of these diagnosis codes complied with federal requirements.
HHS announces plans to revive childhood vaccine task force
The Department of Health and Human Services (HHS) said this week it will reinstate the Task Force on Safer Childhood Vaccines, a federal panel created by Congress to improve the safety, quality, and oversight of vaccines administered to American children.
The original task force was disbanded in 1998, and HHS said the decision to revive it reaffirms its commitment toward continuous improvement in childhood vaccine safety oversight. The task force will be made up of senior leaders from the National Institutes of Health (NIH), the Food and Drug Administration, and the Centers for Disease Control and Prevention. NIH Director Jay Bhattacharya will chair the panel.
The committee will work with the Advisory Commission on Childhood Vaccines to produce regular recommendations focused on the development and improvement of childhood vaccines. HHS said it will provide a formal report to Congress within two years and update the report every two years thereafter.
AHIP study: MA delivered higher-quality care than FFS before and during COVID-19
New research, conducted by AHIP and published by The American Journal of Managed Care (AJMC), found that Medicare Advantage (MA) plans outperformed Traditional Medicare (TM) on clinical quality care measures in 2019 and 2021.
The six-member research team, all employees of AHIP, a national trade association that represents the health insurance industry and includes MA plans as its members, conducted the retrospective cohort study examining beneficiaries enrolled in Medicare from 2017 through 2021.
The authors studied 3.1 million Medicare beneficiaries who were divided into four cohorts based on their enrollment in TM or MA and the year before the start of the COVID-19 pandemic and 2021. They constructed 12 clinical quality measures for each group. The benchmarks included four screenings requiring in-person visits and eight medication management and adherence measures.
Among their findings:
- MA plans outperformed TM on clinical quality care measures in 2019 and 2021.
- Both MA and TM experienced a decrease in screening measures that required in-person visits during the COVID-19 pandemic, with a slightly higher decrease for the MA plans.
- Measures of medication management and adherence improved during the COVID-19 pandemic for both programs, but especially for MA plans.
The study findings, AHIP said in an announcement, add to a growing body of evidence that MA’s coordinated, value-based approach delivers superior quality and better health outcomes—while saving beneficiaries an average of more than $3,400 per year versus FFS.
3 findings from Medicare vision benefit study
A new study conducted by eye health company VSP® Vision Care and the consulting firm Advisory Board examines Medicare and Medicare Advantage members’ preferences and practices regarding vision care.
The study of 757 seniors across the United States included 500 Medicare Advantage members, 212 with traditional Medicare, and 45 who had both Medicare and Medicaid. All had vision care in their health insurance coverage, but only 81 percent used their vision care in the last two years.
Among the key findings:
Vision care influences Medicare Advantage plan selection: Vision benefits were the third most considered factor when selecting a plan, and 77 percent said the availability of vision coverage influenced their decision in some way.
Eye exams provided early detection of chronic disease: Thirty-six percent of respondents with multiple sclerosis and 20 percent with autoimmune diseases or strokes said their illnesses were first identified through an eye exam.
Access and convenience of providers makes a difference: When asked to rank vision provider options in order of importance, 88 percent of consumers ranked appointment availability and 74 percent graded proximity or convenience of access points in their top three options.
To learn more, click here to download the 24-page report.