RISE reviews the latest headlines that impact Medicare Advantage plans.

OIG report: MA encounter data lacks key information needed to combat fraud

A new Office of the Inspector General report finds that 60 percent of the 2018 Medicare Advantage (MA) encounter records for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), laboratory, imaging, and home health services, were missing a national provider identifier (NPI) for an ordering provider. Although this is not a current requirement, the OIG and CMS considers the NPI information essential to combat fraud.

The report found that almost all MA organizations have data systems that can receive and store NPIs when providers submit them on claims or encounter records. A majority also require NPIs to be submitted for their other lines of business, such as commercial and private health insurance, Medicaid, and the Children’s Health Insurance Program.

The OIG recommends that CMS requires MA organizations to submit the ordering provider NPI on encounter records for DMEPOS and for laboratory, imaging, and home health services; and establish and implement “reject edits” that will refuse to accept encounter records in which the ordering provider NPI is not present when required and also reject encounter records that contain an ordering provider NPI that is not a valid and active NPI in the National Plan and Provider Enumeration System (NPPES) registry. CMS concurred with the first recommendation but did not concur with the second recommendation.

CMS interim final rule includes change to disaster policy for MA star ratings due to COVID-19

CMS this week released an interim final rule that includes a change to a policy on how disasters impact the calculation of Star ratings for MA and Part D plans. Until now, the agency would adjust an MA or Part D plan’s Star ratings if 60 percent or more of its members were in a federally designated disaster area. But because the COVID-19 pandemic has affected all contracts in 2020 and most of the country has been designated as individual assistance area, CMS has created special rules for the 2020 Star ratings to remove the 60 percent rule. This change will avoid the agency from excluding the majority of contracts from the methodology it uses to assign Star ratings, which would result in unreliable ratings or missing data for all contracts in the 2022 Star ratings.

Without the change to the current policy rule to calculate the measure-level cut points for the 2020 Star ratings, CMS said it would not have enough contracts to reliably calculate the non-CAHPS measure-level cut points.

RELATED: CMS announces changes to 2021- and 2022-Star ratings data calculations in response to COVID-19

CMS said the changes are also meant to avoid inadvertently creating incentives for plans to place cost considerations above efforts to address care of patients during the COVID-19 pandemic  if they believe that quality performance in 2020 wouldn’t factor into their Star rating for 2022.