CMS to Audit MA Payments Back to 2018

[somarco]

All MA contracts will be audited to complete an unfinished backlog dating back to payment year 2018. The agency will increase its volume of audits per year to identify and collect federal overpayments.


"We are committed to crushing fraud, waste and abuse across all federal healthcare programs," said CMS Administrator Mehmet Oz, M.D., in a news release. "While the administration values the work that [MA] plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients."

https://www.fiercehealthcare.com/payers/cms-deploying-more-coders-advanced-systems-audit-all-medicare-advantage-contracts

Cue the intro to Dragnet . . .

 

[sshafran]

All MA contracts will be audited to complete an unfinished backlog dating back to payment year 2018. The agency will increase its volume of audits per year to identify and collect federal overpayments.


"We are committed to crushing fraud, waste and abuse across all federal healthcare programs," said CMS Administrator Mehmet Oz, M.D., in a news release. "While the administration values the work that [MA] plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients."

https://www.fiercehealthcare.com/payers/cms-deploying-more-coders-advanced-systems-audit-all-medicare-advantage-contracts

Cue the intro to Dragnet . . .

I'm a fan of auditing MA carriers and any person or entity receiving taxpayer money.

 

[Midlevel]

I'm betting they could almost relinquish the federal debt if they audit all Medicare claims dating back to 2018 including MA and Original Medicare claims. Hey Oz, don't forget to look at those nursing homes and all their bogus therapy claims. That would be billions a year alone on OM. Problem is reclaiming all those corrupt claims. On MA they will just fine each company to collect money back but hard to get money out of broke nursing homes who screw OM every minute of every day.

 

[sshafran]

Hey Oz, don't forget to look at those nursing homes and all their bogus therapy claims. That would be billions a year alone on OM.

I wonder how many people on Plan G recover on day 99 just enough to go home...even though they could have on day 55...

 

[somarco]

nursing homes who screw OM every minute of every day.

Gosh, I would love to see the citation for this assertion.

Plan G recover on day 99 just enough to go home...even though they could have on day 55...

Supporting data?

 

[sshafran]

Supporting data?

Suspicion - I said I wonder (and I do) which is why an audit would be helpful.

My only only "proof" is purely anecdotal, so it's not really proof at all. My client around age 74 told me that her husband was in a SNF (her husband - Plan G). She said (her words) that he was there longer than he needed to be but they wanted to keep him there. She did not know why - she said he would have been ok at home by about a month. But after 3 months he was out - shockingly close to the 100 day point, right when the insurance runs out. The cynical side of me thinks: well, they were getting a payday so they weren't in a rush. Maybe I'm wrong.

I generally know SNFs have a bad reputation so it would not shock me to hear that they are not in a rush to push out the Plan F / G folks when they're making money.

 

[somarco]

No doubt, some providers push the envelope to see how far they can go. Are they putting their thumb on the scale to get more revenue? Probably. Is it wide spread? Maybe, but I doubt it.

Medicare covers all costs for the first 20 days. For days 21 - 100 there is currently a daily copay of $209 which is covered by most Medigap plans.

According to Google, the average stay in a SNF is 28 days. Average nursing home stay is much longer.

Patients may stay as long as the confining medical condition needs special care.

SNF's are routinely audited every 18 months and continued stay in the facility is supposed to be monitored by the patient's provider.

If everyone who checked into a SNF magically got well by day 100 I feel certain someone from the IG's office would be making a surprise inspection.

I seriously doubt that, as some allege, a 100 day stay in a SNF is the "norm".

Apologies to George Wendt . . .