Insurance Companies Pocketing Millions in Overpayments Through Their Medicare Advantage Subsidiaries, Audits Find

McKnight’s Senior Living | By Kathleen Steele Gaivin
 
The Centers for Medicare & Medicaid Services released the results of 90 audits of Medicare Advantage plans. The federal audits discovered $12 million in net overpayments for the care of 18,090 patients sampled, Kaiser Health News reported Monday.
 
CMS released the audits to settle a Freedom of Information lawsuit KHN filed against the agency just over three years ago. The audits looked at billings from 2011 through 2013, which are the most recent reviews completed, according to KHN.
 
Currently 46% of Medicare-eligible older adults are enrolled in MA plans. That number is expected to exceed 50% within the next few years.
 
“It’s incredibly frustrating that it took a lawsuit and years of pushing to make this vital information public,” Thomas Burke, a San Francisco attorney who represented KHN pro bono, said in an article published on KHN’s website last month.
 
Medicare Advantage plans primarily are run by major insurance companies. As the plans have grown in popularity as an alternative to traditional  Medicare coverage, they have fallen under increased scrutiny, as previously reported by McKnight’s. Last spring, the Office of Inspector General accused MA organizations of denying or delaying services that met Medicare coverage and MA billing rules. In August, CMS published a request for information, asking the public to provide input regarding various aspects of MA plans. Several home care organizations, including the National Association for Home Care and Hospice and the Partnership for Quality Home Healthcare, urged CMS to ensure that MA plans provide the same level of care as fee-for-service plans and release patients from hospitals to home healthcare in a timely fashion.
 
According to KHN, federal regulators have said they intend to extrapolate the payment error rates from those samples across the total membership of each plan — and recoup an estimated $650 million as a result. The audits go back more than a decade, yet there has been no attempt to recover the losses. CMS was set to unveil a final extrapolation rule Nov. 1, but that didn’t happen. The agency has now pushed that action off until February. 

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New Boosters Add Limited Protection Against Covid-19 Illness, First Real-World Study Shows

By Brenda Goodman, CNN

Updated Covid-19 boosters that carry instructions to arm the body against currently circulating Omicron subvariants offer some protection against infections, according to the first study to look at how the boosters are performing in the real world. However, the protection is not as high as that provided by the original vaccine against earlier coronavirus variants, the researchers say.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, called the new data “really quite good.”

“Please, for your own safety, for that of your family, get your updated Covid-19 shot as soon as you’re eligible to protect yourself, your family and your community,” Fauci said at a White House briefing Tuesday.

Uptake of the bivalent boosters, which protect against the BA.4/5 subvariants as well as the original virus strain, has been remarkably slow. Only 11% of eligible Americans have gotten them since they became available in early September.

The new study found that the updated boosters work about like the original boosters. They protect against symptomatic infection in the range of 40% to 60%, meaning that even when vaccine protection is its most potent, about a month after getting the shot, people may still be vulnerable to breakthrough infections.

That’s in about the same range as typical efficacy for flu vaccines. Over the past 10 years, CDC data shows, the effectiveness of the seasonal flu vaccines has ranged from a low of 19% to a high of around 52% against needing to see a doctor because of the flu. The effectiveness varies depending on how similar the strains in the vaccine are to the strains that end up making people sick.

The authors of the new study say people should realize that the Covid-19 vaccines are no longer more than 90% protective against symptomatic infections, as they were when they were first introduced in 2020.

“Unfortunately, the 90% to 100% protection was what we saw during like pre-Delta time. And so with Delta, we saw it drop into the 70% range, and then for Omicron, we saw it drop even lower, to the 50% range. And so I think what we’re seeing here is that the bivalent vaccine really brings you back to that sort of effectiveness that we would have seen immediately after past boosters, which is great. That’s where we want it to get,” said Dr. Ruth Link-Gelles, an epidemiologist at the US Centers for Disease Control and Prevention.

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With Home Health Rule Unveiled, All Eyes are on HHVBP

McKnight's Home Care | By Liza Berger

A big exhale seemed to sound from the industry last week after the release of the final Medicare home health rule. No question the measure was imperfect, but it helps clear the way for firms to make plans and prepare for other regulatory changes. And of the latter, there are some big ones, including the start of the Home Health Value-Based Purchasing (HHVBP) model, which goes live nationally Jan. 1.

Not unlike the home health rule, there is much anticipation for the HHVBP model, which is based on how well an organization ranks compared  to its peers. Under the expanded initiative, home health agencies receive adjustments to their Medicare fee-for-service payments based on their performance against a set of three quality measures relative to their peers’ performance: Data from Outcome and Assessment Information Set (OASIS), completed Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) surveys and claims-based measures.

The Centers for Medicare & Medicaid Services has been bullish on this model ever since it tested it in nine states starting in 2016. The original model resulted in an average of 4.6% improvement in HHAs’ total performance scores and an average savings of $141 million to Medicare. Evaluation of the original model also found reductions in unplanned acute care hospitalizations and skilled nursing facility (SNF) stays, resulting in reductions in inpatient and SNF spending.

Understandably, the home health industry has voiced reservations toward the national expansion of HHVBP. Due to feedback from provider groups such as the National Association for Home Care & Hospice, CMS delayed the start of HHVBP to 2023. In the recent home health rule, CMS established 2022 as the baseline line. 2025 is the first payment year for the program.

The program symbolizes the ethos of healthcare at the moment: paying for value as opposed to volume, focusing on quality and savings, and keeping people out of the hospital. As companies and consultants continue to remind us, if you are not yet on board the value-based care bus, it’s time to purchase a ticket. Learn more about HHVBP  and how to prepare for it.

CMS Care Compare to Offer More New Information on Home Health-Physician Relationships

Home Health Care News | By Andrew Donlan

Care Compare – the all-in-one search tool for consumers seeking home health, hospice and other Medicare-reimbursed health care services – will now include new information on providers’ relationships with doctors and clinicians.

The U.S. Centers for Medicare & Medicaid Services (CMS) announced the update on Monday.

According to CMS, the new update is meant to “provide additional information to support patients and caregivers as they make health care decisions.” The update, the agency noted, will also offer “information about clinicians who aren’t affiliated with a hospital but work in other types of health care facilities.”

Specifically, the update will be found under the “Doctors and Clinicians” section on Care Compare.

In addition to showing Medicare beneficiaries and their families which home health and hospice providers physicians are linked to, the update will include details on affiliations with skilled nursing facilities (SNFs), long-term care hospitals (LTCHs), in-patient rehabilitation facilities (IRFs) and dialysis facilities.

Broadly, the update is part of CMS’ effort to make Care Compare more transparent and seamless across the major health care settings.

Prior to the Monday announcement, one of the most recent changes to Care Compare was adding Medicare-certified nursing home ownership data to the tool. In April, CMS also released data publicly – for the first time ever – on mergers, acquisitions, consolidation and changes of ownership for hospitals and nursing homes enrolled in Medicare.

“We’re taking another major step forward in improving transparency in health care,” CMS Administrator Chiquita Brooks-LaSure said at the time.

Adding insight on physician and clinician affiliations comes roughly 2 years after CMS consolidated all its different “Compare” tools into today’s one-stop shop. Originally, there were seven different Compare sites for the various Medicare-reimbursed health care settings.

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