MA Companies Driving Payments Up with Chart Reviews & HRAs

The U.S. Department of Health and Human Services Office of Inspector General (OIG) recently released a report reviewing 2016 data which found that 20 of the 162 MA companies drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and HRAs, and on no other service records.

What’s more, each company generated a share of payments from these chart reviews and HRAs that was more than 25 percent higher than its share of enrolled MA beneficiaries. Among these 20 MA companies, 1 company further stood out in its use of chart reviews and HRAs to drive risk adjusted payments without encounter records of any other services provided to the beneficiaries for those diagnoses. This company had 40 percent of the risk-adjusted payments from both mechanisms, yet enrolled only 22 percent of MA beneficiaries. In addition, this company accounted for about a third of all payments from diagnoses reported solely on chart reviews and more than half of all payments from diagnoses reported solely on HRAs.

OIG suggested 3 recommendations for the Centers for Medicare & Medicaid Services (CMS) to address this, including providing oversight of the 20 MA companies that had a disproportionate share of the risk-adjusted payments from chart reviews and HRAs.

By integrating a clean-claims processing tool on the front-end, before a claim is sent to the payor, RemitOne™ restructures the workflow to drastically reduce payor reliance on claim edits and reviews. This in turn can address this issue while saving time and resources associated with human audits. This adapted workflow effectively mitigates FW&A, resulting in a significant decrease in improper payments. Contact our team at info@mccremitone.com to find out how you can utilize RemitOneTM to address compliance issues and improper payments!

To see more about MCC and RemitOne, visit our documentary segment that aired on CNBC here: https://www.mccremitone.net/r1video/MCC_03.mp4.