Medicare Advantage (MA) plans are currently facing scrutiny for potential upcoding and misuse of health risk assessments and chart reviews.

Concerns Raised by the Department of Health and Human Services Office of Inspector General (OIG)

The OIG has raised concerns about major insurers like UnitedHealth Group and Humana inflating their Medicare payments through questionable practices.

The OIG report estimates that approximately $7.5 billion in risk-adjusted payments were received by MA insurers based solely on diagnoses identified during chart reviews, without corresponding service records to support these claims.

This raises questions about the accuracy of the reported diagnoses and whether patients were adequately treated.

Disparity in Payment Structures

The report also highlights a significant disparity in payment structures between at-home visits and facility-based chart reviews, with MA companies receiving much higher payments for at-home visits.

The OIG has recommended stricter regulations and audits to ensure accuracy and compliance in reporting diagnoses from at-home chart reviews.

Specific Conditions and Overpayments

The report identifies specific conditions that accounted for a large portion of the risk-adjusted payments, including vascular disease, major depressive disorders, immunity issues, morbid obesity, and chronic obstructive pulmonary disease.

The federal government is calling for increased scrutiny of MA insurers to address overpayments and ensure the integrity of the Medicare Advantage program.