Fraud in Medicare Advantage, which now covers more than half of all Medicare beneficiaries, has been flagged as a top enforcement priority for CMS and the Department of Justice, which makes now the perfect time to take a closer look at what it means for medical practices.
As First Healthcare Compliance’s main goal is to protect medical practices from compliance risks, we are always looking for new ways in which we can do that, notably by discussing these topics with experts. Yet there is always more to learn. So here are a few quick things to know about Medicare Advantage Fraud, and how best to safeguard your patients from fraud.
Medicare Advantage Bills Differently from “Traditional” Medicare
Medicare Advantage is private sector based. Medicare gives plans an agreed upon amount per plan enrollee in exchange for assuming financial risk and complying with program rules. So under traditional Medicare, one would elect to work directly with CMS. Under Medicare Advantage, third party plans act as the conduits or the intermediaries for administering plans. So unlike the fee for service, how in the physician fee schedule, which is how “traditional” Medicare is reimbursed, under Part C premiums are calculated on a geographic basis through a benchmark bid rebate formula. Additionally, there is a method to calculate what to pay a health provider based on a patient’s health, their likely use of healthcare services and the cost of those services.
The Fraud is in the Details
CMS collects medical diagnosis codes from the Medicare Advantage organizations. And these diagnoses must be supported in the medical record: any time a claim is submitted, whether it’s to a government payer or to a private insurer, the claim has to meet certain standards. These can include an initial face-to-face visit between a patient and a provider, or having the required or affected patient care treatment or management at a particular visit for outpatient visits. All of which are areas ripe with the potential for fraudulent claims.
Many Fraud Cases are Hidden in Plain Sight
By submitting claims and submitting data that is inflated or factually false, fraudulent claimants take advantage of Medicare relying on the accuracy of that data and information submitted by the plans in order to ascertain what the reimbursement will be for the next year. This creates an incentive to make patients appear sicker than what is substantiated in order to skew the risk adjustment score and obtain higher reimbursement rates.
How can Practices Best Protect their Patients and Practice?
A robust compliance program is the first defense, and would include proper employee training across all levels of the organization, to know what to look for in case of fraud, waste, and abuse. In addition, steps as simple as having employees double check notes taken during examinations, and compare those notes diligently against any orders made for a patient, can go a long way towards preventing some of the most common types of Medicare Advantage Fraud. Never blindly trusting either members of your organization or those outside (with some notable fraud cases involving partnerships between medical professionals and insurers), but remaining vigilant against potential issues, is key to making sure that your practice and your patients are safeguarded.
