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CMS to conduct audits, review risk adjustment payments

The United States Department of Health and Human Services Office of Inspector General (OIG) recently released the findings from a study that focused on the Centers for Medicare and Medicaid Services (CMS) provision of unsupported risk adjustment payments. The OIG questioned the CMS' failure to support the risk adjustment payment requests from Medicare Advantage organizations (MAOs) when the MAO failed to provide evidence it conducted a face-to-face appointment to support the requested payment.

What was the OIG's concern?

The OIG stated the CMS' system led to improper payments to MAOs. The OIG stated CMS' current system does not require submission of data to establish a face-to-face visit was made with the patient. The law requires this visit to support the MAO's requested claim for a risk adjustment payment.

The OIG stated this procedure likely created a loophole that could leave the CMS open to potential abuse.

What did the OIG recommend the CMS do to close this loophole?

The OIG recommended the CMS enact a three-part response to address the problem:

  • Oversight. First, the agency recommended the CMS review MAOs that submitted claims for payments without supplying data to show a face-to-face appointment justified the request.
  • Audit. The OIG also recommended the CMS conduct audits to better ensure the provided payments were warranted.
  • Reassess. The agency also encouraged the CMS to review whether or not the benefits of allowing submission for the claim without a link to a chart establishing the face-to-face appointment requirement was wise.

The CMS agreed with the recommendations.

What does this mean for MAOs?

Medical organizations that request such payments from Medicare and Medicaid may find themselves under increased government scrutiny. As such, it is wise to make sure all paperwork to support claims is in order and review procedures to better ensure claims are in compliance with HHS rules.

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