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OIG Says CMS Does Not Ensure Part D Denies Part A Drugs A new audit report from the Department of Health and Human Services Office of Inspector General (HHS OIG) is calling on CMS to enact certain reforms to prevent Medicare Part D from making additional payments for drugs that are supposed to be covered under the Part A benefit. Certain drugs that might normally be under Part D are under Part A when someone is in hospice or in certain facilities. Medicare Advantage and Part D plans should proactively determine what part of Medicare should be charged. This has been a long-standing issue in the Medicare program. The audit looked at more than 2.5 million prescription drug events (PDE) for 2018 through 2020. It looked at anomalies in a sample. Extrapolating the results, it says Part D improperly paid up to $465.1 million. About $245.4 million of that amount

HHS OIG Accuses MA Plans Of Inflating Risk Adjustment Submissions In a follow-up to an earlier review, the Health and Human Services’ Office of Inspector General (HHS OIG) concluded that Medicare Advantage (MA) insurers could be using health risk assessments (HRAs) to inflate risk adjustment payments through upcoding. The OIG says an estimated $7.5 billion in risk-adjusted payments tied to HRAs was received by MA insurers but the diagnoses substantiating them did not appear on separate encounters. Just 20 MA companies drove 80% of the questionable revenue. HHS OIG recommends a series of reforms. UnitedHealth Group received two-thirds of such risk-adjusted payments despite only managing 28% of MA enrollees. I have previously said MA plans should get ready for restrictions or elimination of HRAs and chart reviews in risk adjustment. However, the Centers for Medicare and Medicaid Services (CMS) did not concur with the HHS OIG findings, saying the study

Centene Next To Sue CMS Over Star Ratings Centene has become the latest big Medicare Advantage (MA) plan to sue the Centers for Medicare and Medicaid Services (CMS) over its 2025 Star ratings. United and Humana have already done so. As with the other two plans, Centene argues with CMS’ call center measures. Its complaint raises three fundamental issues. First, relying on a handful of secret shopper calls in a given measure is unreasonable. Second, the 5-Star score requires 100% of TTY calls to be successfully completed and inclusion of even a single incorrect TTY call in the denominator has significant negative impact. Third, CMS mishandled and scored one TTY call to Centene’s detriment. Centene says the one call will cost the plan $73 million in revenue. In other news, brokers and agents are very worried about the impact of major reductions in the MA and standalone Part D (PDP)