Of these 18 million people, 3.8 million people will become completely uninsured, according to the Urban Institute’s report. The estimate is higher than HHS’ August prediction of 15 million people losing coverage after the public health emergency.
If the Covid-19 public health emergency expires in April, about 18 million people could lose Medicaid coverage, a new report concludes.
The Urban Institute, which published the report, found that of these 18 million people, 3.8 million people will become completely uninsured. About 3.2 million children will likely move from Medicaid to separate Children’s Health Insurance Programs. Additionally, about 9.5 million people will receive employer-sponsored insurance. Lastly, more than 1 million people will enroll in a plan through the nongroup market.
The Urban Institute’s estimates, published Monday, is higher than the U.S. Department of Health & Human Services’ (HHS) prediction of 15 million people losing coverage after the public health emergency ends. HHS’ report was published in August and stated that 17.4% of Medicaid and Children’s Health Insurance Program enrollees would leave the program. The Urban Institute’s report did not provide a percentage.
To conduct the study, researchers from the Urban Institute relied on the most recent administrative data on Medicaid enrollment, as well as recent household survey data on health coverage. It used a simulation model to estimate how many Americans will lose Medicaid insurance.
In 2020, Congress passed the Families First Coronavirus Response Act due to the Covid-19 pandemic. It barred states from disenrolling people during the public health emergency, and in return, states received a temporary increase in the federal Medicaid match rates. From February 2020 to June 2022, Medicaid enrollment increased by 18 million people, an unprecedented number, according to the Urban Institute.
Currently, the public health emergency is set to end in January. But since the government has to provide a 60-day notice before the expiration —and did not do so in November — it is expected to be extended to April.
Because many of the affected enrollees who will lose Medicaid coverage will be eligible for coverage through federal or state Marketplaces, the Urban Institute recommends coordination between the Marketplaces and state Medicaid agencies
Researchers called on the government to take action so Americans are prepared for the end of the public health emergency.
“State Medicaid officials and policymakers must continue to ensure that individuals currently enrolled in Medicaid are aware of the approaching end of the public health emergency, and that they have a plan to maintain or find new health coverage through their employer, the federal healthcare Marketplace, or Medicaid,” the Urban Institute said.
Nearly 3.4 million people have signed up for 2023 Affordable Care Act insurance coverage since the start of open enrollment on Nov. 1, a record-setting pace that is a 17% boost over last year, new federal data shows.
The signup data released Tuesday by the Centers for Medicare and Medicaid Services shows a major hike in new signups on HealthCare.gov.
“We are off to a strong start — and we will not rest until we can connect everyone possible to healthcare coverage this enrollment season,” Department of Health and Human Services Secretary Xavier Becerra said in a statement Tuesday.
The nearly 3.4 million in signups represents activity through Nov. 19 on HealthCare.gov, which is used by residents in 33 states to pick an ACA plan, and through Nov. 12 for the 16 states and District of Columbia that run their own marketplaces.
There are 655,000 people who are new to the exchanges that picked a plan already, making up 19% of the total plan signups so far. CMS added that 2.7 million people who already have 2022 coverage renewed or selected a new plan for 2023.
“These plan selection numbers represent a 17% increase in total plan selections over last year,” CMS said in a release.
There is especially major growth on HealthCare.gov, which has seen 493,216 new enrollees compared to 354,137 for the same time period last year.
“Providing quality, affordable health care options remains a top priority,” said CMS Administrator Chiquita Brooks-LaSure in a statement. “The numbers prove that our focus is in the right place.”
The new signups come as the Biden administration made new investments in expansions for marketing and outreach, including record-setting funding for the ACA navigator program. Administration officials are hoping for another robust period of signups thanks to enhanced subsidies to lower insurance costs.
“Four out of five people will be able to find a plan for $10 or less after tax credits,” CMS said.
The boosted tax credits were supposed to expire after this year but have been extended into 2025 by the Inflation Reduction Act.
The 2022 coverage year saw a record 14.5 million signups. The latest open enrollment for HealthCare.gov for 2023 coverage will run through Jan. 15.
The Department of Health and Human Services (HHS) appears set to extend the federal COVID PHE past its current expiration date of January 11, 2023, as HHS had promised to give stakeholders at least 60 days’ notice before ending it, and that deadline came and went on November 11th. Days later the Senate voted to end the PHE, a bill which Biden has promised to veto should it reach his desk. Measures set to expire with the PHE, or on a several month delay after it ends, include Medicare telehealth flexibilities, continuous enrollment guarantees in Medicaid, and boosted payments to hospitals treating COVID patients.
The Gist: Despite growing calls to end the PHE declaration, and even as White House COVID coordinator Dr. Ashish Jha has said another severe COVID surge this winter is unlikely, the White House is likely trying to buy time to resolve the complicated issues tied to the PHE, some of which must be dealt with legislatively.
And with a divided Congress ahead, it remains to be seen how these issues, especially Medicare telehealth flexibilities—a topic of bipartisan agreement—are sorted out. Meanwhile the continuation of the PHE prevents states from beginning Medicaid re-determinations, allowing millions of Americans to avoid being disenrolled.
Millions are about to lose Medicaid while still eligible.
President Biden recently said that the pandemic is “over.” Regardless of how you feel about that statement or his clarification, it is clear that state and federal health policy is and has been moving in the direction of acting as if the pandemic is indeed over. And with that, a big shoe yet to drop looms large — millions of Americans are about to lose their Medicaid coverage, even though many will still be eligible. This amounts to a self-inflicted wound of lost coverage and a potential crisis for access to healthcare, simply because of paperwork.
An August report from HHS estimated that about 15 million Americans will lose either Medicaid or Children’s Health Insurance Program (CHIP) coverage once the federal COVID-19 public health emergency (PHE) declaration is allowed to expire. Of these 15 million, 8.2 million are projected to be people who no longer qualify for Medicaid or CHIP — but nearly just as many (6.8 million) will become uninsured despite still being eligible.
Why Is This Happening?
This Medicaid “cliff” will happen because the extra funding states have been receiving under the Families First Coronavirus Response Act (FFCRA) since March 2020 was contingent upon keeping everyone enrolled by halting all the bureaucracy that determines whether people are still eligible. Once all the processes to redetermine eligibility resume, the lack of up-to-date contact information, requests for documentation, and other administrative burdens will leave many falling through the cracks. A wrong address, one missed letter, and it all starts to unravel. This will have potentially devastating implications for health.
When Will This Happen?
HHS has said they will provide 60 days’ notice to states before any termination or expiration of the PHE — and they haven’t done so yet. It also seems incredibly unlikely that they would announce an end date for the PHE before the midterm elections, as that would be a major self-inflicted political wound. So, odds are that we are safe until at least January 2023 — but extensions beyond that feel less certain.
What Are States Doing to Prepare?
CMS has issued a slew of guidance over the past year to help states prepare for the end of the PHE and minimize churn, another word for when people lose coverage. Some of this guidance has included ways to work with managed care plans, which deliver benefits to more than 70% of Medicaid enrollees, to obtain up-to-date beneficiary contact information, and methods of conducting outreach and providing support to enrollees during the redetermination process.
However, the end of the PHE and the Medicaid redetermination process will largely be a state-by-state story. Georgetown University’s Center for Children and Families has been tracking how states are preparing for the unwinding process. Unsurprisingly, there is considerable variation between states’ plans, outreach efforts, and the types of information accessible to people looking to renew their coverage. For example, less than half of all states have a publicly available plan for how the redetermination process will occur. While CMS has encouraged states to develop plans, they are not required to submit their plans to CMS and there is no public reporting requirement.
Who Will Be Hurt Most?
If you dig into the HHS report, you will see that the disenrollment cliff will likely be a disaster for health equity — as if the inequities of the pandemic itself weren’t enough. A majority of those projected to lose coverage are non-white and/or Latinx, making up 52% of those losing coverage because of changes in eligibility and 61% among those losing coverage because of administrative burdens. Only 17% of white non-Latinx are projected to be disenrolled inappropriately, compared to 40% of Black non-Latinx, 51% of Asian American, Native Hawaiian, and Pacific Islander, and 64% of Latinx people — a very grim picture. This represents a disproportionate burden of coverage loss, when still eligible, among those already bearing inequitable burdens of the pandemic and systemic racism more generally.
Another key population at risk are seniors and people with disabilities who have Medicaid coverage, or those who aren’t part of the Modified Adjusted Gross Income (MAGI) population. Under the Affordable Care Act, states are required to redetermine eligibility at renewal using available data. This process, known as ex parte renewal, prevents enrollees from having to respond to, and potentially missing, onerous re-enrollment notifications and forms. Despite federal requirements, not all states attempt to conduct ex parte renewals for seniors and people with disabilities who have Medicaid coverage, or those who aren’t qualifying based on income. Excluding these groups from the ex parte process has important health equity implications, leaving already vulnerable groups more exposed and at risk for having their coverage inappropriately terminated.
What Can Be Done?
There are ways to mitigate some of this coverage loss and ensure people have continued access to care. HHS recently released a proposed rule that would simplify the application for Medicaid by shifting more of the burden of the application and renewal processes onto the government as opposed to those trying to enroll or renew their coverage. We could also change the rules to allow states to use more data, like information collected to verify eligibility for the Supplemental Nutrition Assistance Program (SNAP), in making renewal decisions, rather than relying so much on income. The Biden administration also made significant investments into navigator organizations, which can help those who are no longer eligible for Medicaid transition to marketplace coverage. Furthermore, states should use this as an opportunity to determine the most effective ways to reach Medicaid enrollees by partnering with researchers to test different communication methods surrounding renewals and redeterminations.
As the federal government and state Medicaid agencies continue to prepare for the end of the PHE, it is critical that they consider who these burdensome processes will affect the most and how to improve them to prevent people from falling through the cracks. More sick Americans without access to care is the last thing we need.
The US Preventative Services Task Force, which is appointed by an arm of the Department of Health and Human Services, issued draft guidance this week recommending that all adults under age 65 be screened for symptoms of anxiety disorders.
The panel made a similar recommendation for children and teenagers earlier this year. COVID accelerated an already widespread mental health crisis, with the prevalence of anxiety and depression increasing by 25 percent globally during the first year of the pandemic. The panel’s recommendations are not mandatory, but carry strong influence over primary care physician practices. Draft guidance will be finalized in the coming months after a review of public comments.
The Gist: Policymakers and providers are right to respond to the population-wide increase in anxiety and depression brought on by COVID, and regular screenings will surely help quantify the scope of a problem we’re now facing.
However, given our nation’s undersupply of behavioral health practitioners, widespread screenings are likely to unleash a flood of demand that traditional providers will struggle to meet. Given virtual care’s staying power in the behavioral health space, we hope that the inevitable wave of mental health diagnoses will be matched with innovative care models designed to treat this growing issue at scale.
Children, young adults will be impacted disproportionately, with 5.3 million children and 4.7 million adults ages 18-34 predicted to lose coverage.
Roughly 15 million people could lose Medicaid coverage when the COVID-19 public health emergency ends, and only a small percentage are likely to obtain coverage on the Affordable Care Act exchanges, according to a new report from the Department of Health and Human Services.
Using longitudinal survey data and 2021 enrollment information, HHS estimated that, based on historical patterns of coverage loss, this would translate to about 17.4% of Medicaid and Children’s Health Insurance Program (CHIP) enrollees leaving the program.
About 9.5% of Medicaid enrollees, or 8.2 million people, will leave Medicaid due to loss of eligibility and will need to transition to another source of coverage. Based on historical patterns, 7.9% (6.8 million) will lose Medicaid coverage despite still being eligible – a phenomenon known as “administrative churning” – although HHS said it’s taking steps to reduce this outcome.
Children and young adults will be impacted disproportionately, with 5.3 million children and 4.7 million adults ages 18-34 predicted to lose Medicaid/CHIP coverage. Nearly one-third of those predicted to lose coverage are Hispanic (4.6 million) and 15% (2.2 million) are Black.
Almost one-third (2.7 million) of those predicted to lose eligibility are expected to qualify for marketplace premium tax credits. Among these, more than 60% (1.7 million) are expected to be eligible for zero-premium marketplace plans under the provisions of the American Rescue Plan. Another 5 million would be expected to obtain other coverage, primarily employer-sponsored insurance.
An estimated 383,000 people projected to lose eligibility for Medicaid would fall in the coverage gap in the remaining 12 non-expansion states – with incomes too high for Medicaid, but too low to receive Marketplace tax credits. State adoption of Medicaid expansion in these states is a key tool to mitigate potential coverage loss at the end of the PHE, said HHS.
States are directly responsible for eligibility redeterminations, while the Centers for Medicare and Medicaid Services provides technical assistance and oversight of compliance with Medicaid regulations. Eligibility and renewal systems, staffing capacity, and investment in end-of-PHE preparedness vary across states.
HHS said it’s working with states to facilitate enrollment in alternative sources of health coverage and minimize administrative churning. These efforts could reduce the number of eligible people losing Medicaid, the agency said.
The Inflation Reduction Act of 2022extends the ARP’s enhanced and expanded Marketplace premium tax credit provisions until 2025, providing a key source of alternative coverage for those losing Medicaid eligibility, said HHS.
WHAT’S THE IMPACT?
While the model projects that as many as 15 million people could leave Medicaid after the PHE, about 5 million are likely to obtain other coverage outside the marketplace and nearly 3 million would have a subsidized Marketplace option. And some who lose eligibility at the end of the PHE may regain it during the unwinding period, while some who lose coverage despite being eligible may re-enroll.
The findings highlight the importance of administrative and legislative actions to reduce the risk of coverage losses after the continuous enrollment provision ends, said HHS. Successful policy approaches should address the different reasons for coverage loss.
Broadly speaking, one set of strategies is needed to increase the likelihood that those losing Medicaid eligibility acquire other coverage, and a second set of strategies is needed to minimize administrative churning among those still eligible for coverage.
Importantly, some administrative churning is expected under all scenarios, though reducing the typical churning rate by half would result in the retention of 3.4 million additional enrollees.
THE LARGER TREND
CMS has released a roadmap to ending the COVID-19 public health emergency as health officials are expecting the Biden administration to extend the PHE for another 90 days after mid-October.
The end of the PHE, last continued on July 15, is not known, but HHS Secretary Xavier Becerra has promised to give providers 60 days’ notice before announcing the end of the public health emergency.
A public health emergency has existed since January 27, 2020.
The Biden Administration has released final surprise billing rules implementing the No Surprises Act, a federal law enacted in January 2021 that protects patients from out-of-network medical bills when they seek care at in-network facilities.
The new surprise billing rules detail the process for payers and providers to settle on payment for those out-of-network services. Previously, payers and providers would submit payment rates to an independent arbiter, selected by the government. The arbiter would choose the rate closest to the area’s median in-network payment for the services, otherwise known as the qualifying payment amount (QPA), while considering other factors, such as provider training and experience, the provider’s market share, and how difficult it was to provide the service, after the fact.
Provider groups have criticized the use of the QPA as the primary factor in an arbiter’s decision, arguing that the added weight to the QPA amount favors payers over providers.
Notably, the Texas Medical Association challenged the surprise billing arbitration process over the QPA issue and won. A district court vacated the requirement that arbiters select payment offers closest to the QPA unless the additional information warrants a closer review.
The American Hospital Association (AHA) and the American Medical Association (AMA) have also filed a lawsuit challenging the interim final rule implementing the dispute process, arguing that lawmakers did not intend for rules implementing the No Surprises Act to place that much emphasis on the QPA. The lawsuit is ongoing.
In light of the district court’s decision, the latest final surprise billing rules roll back the “rebuttable presumption” that favors the QPA. The rules state that arbiters are to consider the QPA “and then must consider all additional information submitted by a party to determine which offer best reflects the appropriate out-of-network rate.”
The final rules specify that arbiters “should select the offer that best represents the value of the item or service under dispute after considering the QPA and all permissible information submitted by the parties.”
The final rules also cover situations where payers have “downcoded” a claim. According to previous rulemaking, downcoding occurs when payers change service codes or change, add, or remove a modifier, which can lower the QPA for the service code or modifier billed by a provider.
The rules will create new requirements related to what information payers must share with providers when downcoding occurs. The information includes a statement that the service code or modifier was downcoded, an explanation of why the claim was downcoded, and the amount that would have been the QPA had the service code or modifier not been downcoded.
The Biden Administration—through the Departments of Labor, Health and Human Services, and Treasury, which officially released the final surprise billing rules—said that the rules “will help providers, facilities and air ambulance providers engage in more meaningful open negotiations with plans and issuers and will help inform the offers they submit to certified independent entities to resolve claim disputes.”
But whether the updated language is enough to tip the balance for providers remains to be seen. AHA said in a news release late last week that it is closely reviewing the final surprise billing rules.
More than 180 members of the House of Representatives are urging the Biden administration to crack down on drugmakers restricting drug discounts in the 340B program.
Enforcement actions should include fines, the letter from a bipartisan group of House members to HHS Secretary Xavier Becerra and other administration officials said.
Currently, 18 drug manufacturers are limiting 340B discounts dispensed through pharmacies that contract with 340B providers, according to the letter.
Dive Insight:
The 340B program requires drugmakers to charge hospitals only the statutory ceiling prices for eligible outpatient drugs. The goal of the three-decade-old program is to have savings flow into care for low-income patients and underserved communities. But critics — notably, drugmakers and some lawmakers — argue the program doesn’t have enough oversight, as hospitals don’t need to account for what they do with any savings.
Drug manufacturers began imposing restrictions on 340B discounts as early as summer 2020, sparking legal challenges from regulators. The HHS sent nine warning letters to pharmaceutical companies, referring seven of them to the Office of the Inspector General for investigation and potential enforcement.
However, eight months later, the OIG has yet to take enforcement action, the new letter from 181 House members reads.
The letter asks the OIG to finish its ongoing review of seven drug manufacturers for potential noncompliance with federal law on 340B discounts “as soon as possible.”
The law allows the OIG to impose fines up to $6,000 per drug claim on companies that intentionally overcharge 340B providers, according to the Health Resources and Services Administration, which oversees the program.
Regulators should begin imposing civil monetary penalties against pharmaceutical companies found in violation, the congresspeople said.
The letter also argues that the Biden administration should pursue enforcement action against 11 drug companies restricting 340B pricing, which either haven’t received notice from the HHS that they’re in violation of law yet, or have received a notice but haven’t been referred to OIG for enforcement.
“Every day that drug manufacturers violate their obligation to provide these discounted drugs, vulnerable communities, federal grantees, and safety net health care providers are deprived of resources Congress intended to provide,” the letter reads.
A number of hospital associations came out in support of the letter, including the National Rural Health Association, the American Hospital Association, America’s Essential Hospitals and the National Association of Community Health Centers.
340B Health, which lobbies on behalf of hospitals in the 340B program, thanked the House members for the letter in a statement Monday, and reiterated calls for fines.
“HHS should impose steep financial penalties on all the companies that are ignoring their legal commitments to the health care safety net,” said Maureen Testoni, CEO of 340B Health, in a statement.
A survey of more than 500 hospitals by 340B Health released in May estimated that the annual financial impact from drug company restrictions has doubled since the end of 2021, costing hospitals millions of dollars per year.
Drugmakers that have imposed or announced restrictions on 340B discounts for drugs dispensed at community and specialty pharmacies include AbbVie, AstraZeneca, Johnson & Johnson, Merck and Pfizer.
This week, federal health officials sent hospitals clarification that the federal Emergency Medical Treatment and Labor Act (EMTALA) protects the provision of abortion care during medical emergencies, regardless of state laws. The guidance also offers EMTALA as a possible legal defense for providers against state enforcement of antiabortion laws. Texas Attorney General Ken Paxton has already sued the Department of Health and Human Services (HHS) to set aside the guidance, claiming the agency is exceeding its authority.
The Gist:This latest federal action follows President Biden’s recent executive order directing federal agencies to protect access to reproductive care, and HHS’s warning that pharmacists refusing to dispense medications used to induce abortions could be violating federal civil rights laws. The Federal Trade Commission and Justice Department have also announced that they will enforce data privacy rules and pursue legal action against states that look to restrict patients from traveling to obtain abortion care.
These quick federal actions, while limited, are an attempt provide clarity for providers trying to deliver lifesaving care in a timely manner, without running afoul of state laws. Some Democrats, however, argue that they don’t go far enough, and are pushing for the President to declare a public health emergency on abortion, though it’s not clear that would provide much patient benefit.
Meanwhile, reports from Texas and other states with restrictive abortion laws reveal physicians are already delaying care for ectopic pregnancies and other life-threatening conditions, setting up all-but-certain legal action when patients experience adverse outcomes.
Political will seems to be growing to reshape the increasingly popular Medicare Advantage program.
At a House Energy and Commerce committee hearing on Tuesday, lawmakers on both sides of the aisle called for more oversight of MA following watchdog reports that found impediments to receiving covered care, including improper denials of prior authorization requests, and plans gaming the system in exchange for more funding from Medicare.
“Medicare Advantage is an important tool for helping seniors and we want it to succeed. We’re going to continue to conduct the oversight necessary,” said Oversight and Investigations Subcommittee Chair Diana DeGette, D-Colo.
Witnesses at the hearing — officials from the Government Accountability Office, HHS Office of Inspector General and congressional advisory board MedPAC — also pointed to higher rates of beneficiary disenrollment in their last year of life and opaque plan data, which can complicate oversight efforts.
Surveys have shown MA remains extremely popular with beneficiaries, attracted by lower co-pays and supplemental benefits like vision coverage and telehealth. In the program, Medicare pays private plans a capitated monthly rate to provide care for their beneficiaries based on the severity of their beneficiaries’ needs.
The hearing comes amid inflamed industry debate over the future of MA.
For-profit hospital lobby Federation of American Hospitals submitted a letter for the record sharing concerns over some MA plans denying patient care and having inadequate care networks.
Meanwhile, MA trade group Better Medicare Alliance sent a letter to the CMS on Monday urging the agency to safeguard the program as Congress mulls changes to Medicare.
But as Medicare’s hospital benefit — part of which funds MA — limps towards insolvency, lawmakers appear poised to target the growing MA program in a bid to crack down on improper payments and care denials.
“This is something that I think is very much bipartisan,” said Rep. Gary Palmer, R-Ala.
Coverage delays and denials
It’s not the first time lawmakers have zeroed in on MA oversight as a strategy to save Medicare money: In a Senate hearing on Medicare insolvency in February, Sen. Elizabeth Warren, D-Mass., said “the Medicare system is hemorrhaging money on scams and frauds” due to insurers taking advantage of the program’s rules to increase profits.
Even amid rising congressional criticism of MA, lawmakers on Tuesday reiterated their support for the program overall, which covered roughly 27 million Americans in 2021.
That’s more than a third of all Medicare beneficiaries, though MA is expected to swell to cover half of all Medicare members by 2030.
But lawmakers said they are increasingly concerned about disparities in the quality of coverage offered by Medicare Advantage plans compared to traditional Medicare plans, along with unscrupulous practices in the program resulting in higher reimbursement for MA organizations.
A GAO report found MA beneficiaries in their last year of life disenroll from MA in favor of traditional Medicare at a rate two times higher than other MA members, suggesting the plans may not support high-cost and specialized care, testified Leslie Gordon, GAO’s acting director for healthcare.
Gordon called it a “red flag” for the program that requires more scrutiny from CMS.
In addition, an HHS OIG report published April found MA organizationswrongly denied members care, with plans turning down 18% of payment requests that should have been approved.
Erin Bliss, OIG assistant inspector general in the Office of Evaluation and Inspection, testified plans sometimes use internal critical criteria that are not required by Medicare. In one example, an MA plan denied a medically necessary CT scan to diagnose a serious disease, citing that the patient hadn’t yet received an x-ray, Bliss said.
When appealed, plan denials were reversed 75% of time, a rate DeGette called “alarmingly high.”
“We are concerned that patients are receiving the timely care they need in those situations,” Bliss said.
OIG also found plans denied 13% of prior authorization requests that would have been approved under traditional Medicare.
Rep. Michael Burgess, R-Texas, suggested policymakers consider requiring insurers to forego prior authorization for doctors with a consistent track record of submitting accurate data. That strategy, called “gold carding,” is already used in some states, including Texas and West Virginia, to pare back on prior authorization delays.
MA payment reform
Along with coverage restrictions, lawmakers at Tuesday’s hearing asked witnesses about the scope and severity of improper MA payments in a bid to zero in on specific solutions Congress and the CMS can enact.
Though MA has potential to save the Medicare program money, “the current incentives for MA plans are not adequately aligned with the Medicare program,” said James Mathews, MedPAC executive director.
“Substantial reforms are urgently needed,” especially in light of Medicare’s “profound” financial problems, Mathews said.
In 2022, the average MA plan bid was 85% of fee-for-service spending, Mathews said. However, Medicare pays plans 104% of fee-for-service costs.
That imbalance is partially due to plans making patients appear sicker than they are to get extra payments from the government, witnesses said. The practice, called “coding intensity,”resulted in an estimated $12 billion in excess Medicare spending in 2020, according to MedPAC data.
Methods include chart reviews, where plans identify and add patient diagnoses that aren’t included in the service record, and health risk assessments, where plans contract with vendors to visit beneficiaries homes and conduct assessments, finding new diagnoses that often aren’t backed up by other records, according to Bliss.
GAO estimates that roughly a tenth of Medicare payments to MA plans in 2021 were improper, Gordon said.
To try to tamp down on coding intensity, the CMS should conduct targeted oversight of MA plans that routinely use these tools, and reassess whether chart reviews and in-home assessments are allowed to be sole sources of diagnoses for payment purposes, witnesses said. In addition, MA should improve care coordination for enrollees who receive health risk assessments.
The CMS should also consider replacing the quality bonus program and change its approach to calculating MA benchmarks, Mathews said.
In addition, the agency should require and validate data for completeness and accuracy before risk-adjusting payments through methods like medical record reviews, Gordon said.
Gordon also suggested the agency conduct more timely audits, as the CMS is currently missing out on recouping hundreds of millions of dollars in improper payments.
Policymakers appeared open witnesses’ suggestions to ensure MA is running as smoothly as possible, with Rep. Frank Pallone, D-N.J., calling for an additional hearing on the matter.
“This is bipartisan … You can be assured that we’re going to be following up,” DeGette said.
HENRY KOTULA 