Medicare Advantage Plans and the OIG


Published: 9/13/2017

In July 2017 James Cosgrove, director of health care reviews for the Government Accountability Office, reported the Medicare Advantage improper payment rate for 2016 was 16.2 billion

Pair that with CMS official Jonathan Morse’s statements that the “largest contributors” to billing mistakes in standard Medicare were claims from home health care and inpatient rehabilitation facilities, and improper payments in the MA program are “most often payments for which there is no or insufficient supporting documentation to determine whether the service … was “medically necessary.”

As such, the home health industry should not be surprised at the intensity of Medicare Advantage audits we are just now starting to see. 

As the Silver Tsunami of baby boomers arrives, and the volume of MA claims exponentially increases, it is expected that more auditing of MA claims will be required by the OIG and congress. Home Health providers should know these claims will be targeted in a data driven manner, and what the triggers for those audits are. We know the best time to avoid setting off these triggers is during the OASIS assessment utilizing a Software Assisted Scribing Process.

Standard Medicare has a similar problem making accurate payments to doctors, hospitals and other health care providers, according to recently published statistics, Standard Medicare’s payment error rate was cited at $41 billion for 2016.

As the Medicare payment system transitions from the “honor system” to a hi-tech high- volume data driven claims adjudication environment, successful providers will come to realize compliance with federal payment mandates is a requirement of continued success. Initial compliance by the contractor is far cheaper than the retroactive compliance methods embraced during the past twenty years. 

We suggest you know and manage your data prior to submission. This is the easiest way to position your agency for success!