In The News

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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CMS Updates Medicare Enrollment Instructions

The Health Group

Effective December 5, 2022, certain modifications have been made to Chapter 10 of the Medicare Program Integrity Manual dealing primarily with “Ownership Disclosures”, “Electronic Funds Transfers”, and “Special Payment Addresses”. MM12880 - Provider Enrollment Instructions: Seventh General Update (cms.gov).

Ownership Disclosures:

The provider or supplier must disclose ALL persons and entities that meet the definition of “owner”.

Providers must show the applicable ownership percentage for each owner if required by the specific provider enrollment application being completed.

There cannot be indirect owners without direct owners.

The combined disclosed ownership percentages for the provider or supplier’s organizational and individual owners cannot be greater than 100%.

 

Quality Alert: CMS Care Compare Nov. 2022 Data Refresh

NHPCO

Summary at a Glance

November 23, 2022, publicly reported Hospice Item Set and CAHPS® Survey Family Caregiver Experience hospice quality data were refreshed on Care Compare. Star ratings and claims-based measures were not updated with the November 2022 refresh.

Care Compare data refresh schedules for publicly reported measures are as follows:

  • CAHPS® Hospice Survey Family Experience data – updated quarterly (Current quarters: Quarter 3-Quarter 4 2019 and Quarter 3 2020-Quarter 4 2021) 
  • Hospice Item Set Comprehensive Assessment Measure at Admission – updated quarterly (Current quarters: Quarter 1 2021-Quarter 4 2021)
  • Star Ratings – updated every other quarter (every 6 months), next refresh February 2023 (Current quarters: Quarter 2-Quarter 4 2019 and Quarter 3 2020-Quarter 3 2021) 
  • Claims-Based Measures (Hospice Care Index and Hospice Visits in Last Days of Life) – updated annually, next refresh August 2023 (Current quarters: Quarter 2-Quarter 4 2019 and Quarter 3 2020-Quarter 3 2021)

NHPCO members should download the complete Quality Alert from the NHPCO website to read the full report. Please reach out to [email protected] with any questions.

 

More Payers Adding In-Home Care, Caregiver Support to Medicare Advantage Plans

Becker’s | By Rylee Wilson

More Medicare Advantage plans will offer in-home support services to enrollees in 2023, according to a new report from the Better Medicare Alliance. 

In 2023, 794 plans will offer in-home support, according to the report published Nov. 17 

In-home support services are one of several additional supplemental benefits approved by CMS in 2018. 

Other supplemental benefits include home-based palliative care, adult day health services, therapeutic massage and support for caregivers. A total of 259 plans will offer caregiver support in 2023. 

The number of plans offering at least one supplemental benefit has grown substantially since 2020. For 2023, 1,111 plans will offer supplemental benefits, up from 351 in 2020, according to the report. 

"As seniors contend with rising household costs, their ability to access more benefits that are built into the affordable cost of their Medicare Advantage plan is welcome news," Better Medicare Alliance President and CEO Mary Beth Donahue said in a news release. 

Read the full report here.

 
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