RISE summarizes the latest headlines that have an impact on Medicare and Medicare Advantage.

CMS reports Medicare FFS improper payment rate down by $15B

The Centers for Medicare & Medicaid Services (CMS) credits its aggressive corrective actions for the reduction in an estimated $15 billion of Medicare Fee-For-Service (FFS) improper payments. In an announcement, CMS said the estimated improper payment rate decreased to 6.27 percent in FY 2020, from 7.25 percent in FY 2019, the fourth consecutive year the Medicare FFS improper payment rate has been below the 10 percent threshold for compliance established in the Payment Integrity Information Act of 2019.

The agency attributes this year’s decrease to progress in clarifying home health documentation requirements and educating providers (which led to an estimated $6 billion decrease in estimated improper payments since 2016) and a policy change related to supporting information for physician certification and recertification for skilled nursing facility services (which led to a $1 billion reduction in estimated improper payments). For more information, see the CMS fact sheet on 2020 estimated improper payment rates.

BMA warns flawed 'rebate rule' will lead to increased costs for seniors

Better Medicare Alliance (BMA) has issued a warning in advance of the Trump administration’s possible finalization of its controversial “rebate rule.” If finalized, the rule will eliminate current cost-saving prescription drug rebates for seniors in Medicare Part D plans, including the more than 22 million beneficiaries in Medicare Advantage-Prescription Drug (MA-PD) plans. In an announcement, BMA said that the administration's own actuaries found that such policies could raise Medicare Part D premiums by 19 percent in the first year and 25 percent in the decade thereafter. The administration also provided several cost estimates for the rule’s impact on federal costs, which ranged from saving nearly $100 billion to costing nearly $200 billion.

“It would be deeply unfortunate to see CMS risk undermining its own progress in lowering health care costs for seniors in the final weeks of the current administration with finalization of this ill-conceived rule,” said Allyson Y. Schwartz, president and CEO of BMA, in the announcement. “CMS has touted its work to keep Part D premiums low, yet its own actuaries say this rule could raise Part D premiums by 19 percent in the first year alone—adding a senseless cost burden on seniors at the height of the COVID-19 pandemic.”

MA provider to pay $6.3M to settle False Claims Act allegations

The U.S. Department of Justice on Monday announced that Kaiser Foundation Health Plan of Washington, formerly known as Group Health Cooperative (GHC), agreed to pay $6,375,000 to resolve allegations that it submitted invalid diagnoses to Medicare for Medicare Advantage beneficiaries and received inflated payments from Medicare as a result. Kaiser Foundation Health Plan is headquartered in Oakland, Calif. The settlement resolves allegations that GHC knowingly submitted diagnoses that were not supported by the beneficiaries’ medical records to inflate the payments that it received from Medicare. The allegations were originally brought in a lawsuit filed under the qui tam, or whistleblower, provisions of the False Claims Act by Teresa Ross, a former employee of Group Health. The claims resolved by the settlement are allegations only; there has been no determination of liability, according to the Justice Department.