Priority Health Overpayment Audit
The Health and Human Services (HHS) Office of the Inspector General (OIG) says Priority Health may have collected at least $4.4 million in Medicare Advantage (MA) overpayments throughout 2018 and 2019. The targeted audit focused on ten high-risk diagnosis groups.
Auditors found medical records did not back diagnosis codes across 252 of 300 sampled enrollee-years, prompting $828,010 in net MA overpayments — an 84% error rate. OIG says many codes were for a previous diagnosis that was no longer active.
#medicareadvantage #radv #riskadjustment #overpayments
Wakely Details LEAD
A great Wakely Consulting white paper detailing the ACO LEAD model, which will succeed ACO Reach and run from 2027–2036. LEAD will eliminate rebasing (locking in base years), expand capitation and specialist risk-sharing, integrate high-needs populations into a unified ACO structure, and offer more flexible alignment mechanisms. Benchmarking and value-based care incentives also evolve along while strengthening quality incentives and prevention-focused benefits.
The LEAD model is designed to resolve key limitations of prior models, REACH and the current MSSP. A great grid that compares LEAD, REACH, and MSSP.
#medicare #vbc #acos
https://www.wakely.com/blog/the-lead-model-a-new-chapter-in-medicare-accountable-care/
MA Look-Alike Rule May Not Be Effective
A good Health Affairs Forefront blog examines the changes related to look-alike plans in Medicare Advantage (MA) and what has resulted. In the end, while there have been a few passes at reducing look alike plans, most full-benefit dual eligibles ended up enrolling in plans with little or no Medicare-Medicaid integration. The blog notes that this analysis could be critical to what the Centers for Medicare and Medicaid Services (CMS) may do on the huge growth of Chronic Care Special Needs Plans (C-SNPs).
#medicareadvantage #enrollment #snps
KFF Covers Uninsured
Healthcare policy group KFF covers the uninsured in a new briefer. For the first time since 2019, the number of people without health coverage and the uninsured rate increased in 2024. The total number of people ages 0-64 without health coverage increased by more than 1.3 million to 26.7 million in 2024. The uninsured rate for the population under age 65 increased from 9.5% to 9.8%.
What is interesting is that nearly half (45%) of the remaining uninsured are outside the reach of Affordable Care Act (ACA) Exchange or Medicaid expansion coverage.
#uninsured #healthcare #coverage
— Marc S. Ryan
