Key Lawmakers Urge CMS to Curb Medicare Advantage Fraud, Abuse
McKnight’s Home Care | By Adam Healy The Centers for Medicare & Medicaid Services should take swift action to “curb abusive practices” by Medicare Advantage plans, senators said in a letter sent Thursday. “The MA program is based on the premise that private insurance companies can and would administer Medicare coverage more cost-effectively — but it has failed to do so every single year,” Sens. Pramila Jayapal (D-WA) and Elizabeth Warren (D-MA) wrote in their letter. The Medicare Payment Advisory Commission has estimated that MA plans average receiving as much as 6% more per enrollee than traditional Medicare, the letter writers said. On top of that, MA plans also spend roughly 25% less on healthcare services per enrollee, they noted. “It is imperative for CMS to rein in these abuses and protect Medicare coverage for the seniors and people with disabilities who rely on it,” the senators wrote. Jayapal and Warren recommended improvements in four areas. First, they advised CMS to augment base MA payments to offset overpayments due to favorable selection. Since MA beneficiaries are typically younger and healthier, they wrote, MA insurers may receive higher-than-average reimbursement from CMS while also paying out fewer claims, resulting in “gross overpayments.” They also recommended CMS get more aggressive about recouping overpayments, implement a “network quality” measurement to MA plans’ star ratings, and limit insurers’ use of health risk assessments — which have been criticized for their lack of transparency. Jayapal and Warren also noted MA plans’ use of artificial intelligence to “systematically deny care.” In November, UnitedHealthcare, the largest MA insurer, was alleged in a class action lawsuit to have used artificial intelligence tools to deny hundreds of patients post-acute care services, including home health. Also on Thursday, CMS issued an extensive request for information seeking details about nearly all aspects of the MA program. They include care access data, prior authorization results, statistics related to patients’ outcomes and more. Still, Jayapal and Warren sought further enforcement action in their letter to the agency. They gave qualified praise to steps CMS has already taken to limit overpayments. Nonetheless, they noted, the Committee for a Responsible Federal Budget has projected that CMS will overpay MA insurers by as much as $1.56 trillion over the next decade. “As enrollment in MA continues to grow, CMS must take more aggressive action to ensure Medicare’s sustainability, protect taxpayer dollars, and curb abusive practices,” they said. |
As Denials Climb, MACPAC Approves Recommendations for Managed Care Oversight
McKnight’s Home Care | By Adam Healy
The Medicaid and CHIP Payment Advisory Commission on Friday approved seven recommendations to enhance congressional oversight of Medicaid managed care organizations as recent reports reveal startlingly high rates of prior authorization denials.
MACPAC’s recommendations aim to improve the prior authorization and appeals process by requiring MCOs to report relevant data to the Centers for Medicare & Medicaid Services. CMS would be required to release public reports on the data, as well as update regulations and create additional guidelines for MCOs’ use of prior authorization.
A recent investigation by the Office of the Inspector General found that 12.5% of prior authorization requests were denied by Medicaid MCOs, and about 2.7 million Medicaid beneficiaries were enrolled in MCOs with denial rates greater than 25%.
Thousands of prior authorization requests for elderly, chronically ill or disabled patients requiring home care were denied by MCOs, according to the report.
“Few denials are appealed and little is known about the beneficiary experience,” Lesley Baseman, senior policy analyst at MACPAC, said during the Thursday meeting. “The appeals process is also challenging and burdensome for beneficiaries. Denial notices can be late in the mail and the content is often unclear, and beneficiaries encounter multiple barriers in accessing continuation of benefits.”
Part of the challenge, OIG’s investigation found, was that few guidelines for MCOs’ prior authorizations requests are currently in place.
States are not federally required to collect data on denials, continuation of benefits, or appeals outcomes, according to Baseman. Federal rules do not require states to assess clinical appropriateness of denials, she said, and they do not require that states publicly report information on denials and appeal outcomes.
OIG’s report also found that many MCOs employed staff who were not qualified to approve or deny requests, and most states lack safeguards to identify improper prior authorization denials. |
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Federal Scientists Conclude There is Credible Evidence for Certain Medical Uses of Marijuana
Politico | By Natalie Fertig
The Department of Health and Human Services concluded that marijuana is less harmful than other dangerous drugs and that there is some evidence of its medical benefits in recommending loosening federal restrictions on the drug.
The agency on Friday released a 252-page review outlining the reasoning that the Food and Drug Administration used to come to this conclusion. This and the other findings of the review are a major departure in how the federal government views cannabis. For the last 60-plus years, cannabis has been classified as a Schedule I drug — the same as heroin — under the Controlled Substances Act, which means it’s a substance of high abuse potential and no accepted medical use.
The review was conducted at the request of President Joe Biden, who instructed HHS in an executive order issued in October 2022 to look through all available research on cannabis and recommend if the drug should be moved within the list of federally controlled drugs or removed from it altogether. Bloomberg first reported in August that HHS had recommended marijuana be moved to Schedule III, and the release of these documents on Friday confirms that.
The Drug Enforcement Administration will have the final say in any changes to marijuana’s classification under federal law, with a decision expected in the coming months.
The documents were released to cannabis lawyers Matt Zorn and Shane Pennington and published on their blog On Drugs. The documents were released as a result of a lawsuit brought by Zorn and Pennington.
Cannabis legalization has spread rapidly across the country over the last decade. Two dozen states — representing more than half the U.S population — have legalized possession and use for adults, while 38 states have established medical marijuana programs.
The cannabis review was based on eight different scientific criteria, including its potential for abuse, the state of current scientific knowledge and the likelihood of psychological or physiological dependence. |
Hospice Fraud Back In The Spotlight, With New Data Also Raising Questions About Home Health Care
Home Health Care News | By Robert Holly The number of hospice providers enrolled in the Medicare program in four states has skyrocketed over the past few years. The jaw-dropping spike, in turn, has triggered increased oversight efforts – some of which may not be having the desired effect. A similar trend could be happening in home health care in one major county, U.S. Centers for Medicare & Medicaid Services (CMS) data suggests. In hospice, the surge of new providers and potentially fraudulent activities has been concentrated in Arizona, California, Nevada and Texas. In home health care, it’s Los Angeles County. After becoming aware of the data on new hospice openings and following a series of scathing media reports, CMS implemented a Special Focus Program (SFP), effective Jan. 1, while also finalizing a new rule forbidding change in majority ownership during the 36 months after initial Medicare enrollment, including acquisitions, stock transactions or mergers. In August, the agency additionally announced it was considering administrative action against 400 hospices. “Unfortunately, hospices are profiting from fraud at the expense of beneficiaries far too often,” CMS said at the time. Meanwhile, some of the aforementioned states have pushed forward stronger rules and regulations, too. For example, in 2021, California passed two reform laws that included a moratorium on new hospice provider licenses until the state health department weeded out bad actors. A California Department of Justice (CDOJ) report detailing the state’s history of lax oversight helped fuel that initiative. “The state’s weak controls have created the opportunity for large-scale fraud and abuse,” CDOJ indicated in its report. Back in the spotlight Hospice fraud and the related oversight efforts were back in the spotlight last week, when ProPublica reported that new hospices in California are still receiving Medicare certification with clear instances of fraud happening in the other states as well. In one instance last year, 15 new hospices received Medicare certification, all operating from the same two-story building in Los Angeles, according to ProPublica. In another: A location in Phoenix was approved for three new hospice licenses, all at the same location as dozens of other new providers in the previous two years. According to a review of Medicare claims data shared with Home Health Care News and Hospice News, California had 102 newly enrolled hospices in 2023. In Arizona, the number of new hospices increased by 25 during the same period, while Texas and Nevada saw 72 and 25 new providers, respectively. Across the board, no other state experienced an influx of more than 15 new hospices, with most states reporting single-digit enrollment figures. In total, approximately 69% of all newly licensed hospices in 2023 were situated in Arizona, California, Nevada and Texas.
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