Federal Report Highlights Potential Overpayments in Medicare Advantage Plans Due to Unsupported Stroke Diagnoses
A recent federal report has brought to light significant concerns regarding Medicare Advantage (MA) plans and their handling of stroke diagnoses. The Department of Health and Human Services’ Office of Inspector General (OIG) conducted a detailed examination, revealing that these plans may have resulted in millions of dollars in overpayments due to unsupported acute stroke diagnosis codes.
OIG’s Thorough Examination and Findings
In their comprehensive analysis, the OIG scrutinized 240,401 Medicare Advantage enrollees who were identified as having a high risk for incorrect acute stroke diagnosis codes. From this large pool, a sample of 97 members was extracted for further investigation. Astonishingly, the findings indicated that none of the 97 high-risk acute stroke diagnoses were substantiated by the patients’ medical records.
Based on this sample, the OIG projected that the Centers for Medicare & Medicaid Services (CMS) overpaid MA plans by an estimated $462 million in 2021, solely due to these inaccurate stroke diagnoses.
Previous Audits and Concerns
The report also references prior audits conducted by the OIG, which identified acute stroke diagnosis codes as a high-risk area for overpayments. Specifically, these audits found discrepancies when acute stroke diagnosis codes were entered into physician records without a corresponding acute stroke diagnosis in inpatient or outpatient hospital records within the same year of service.
“This audit focused on this high-risk area across multiple MA organizations to examine whether MA organizations’ submission of these diagnosis codes to CMS complied with federal requirements,” the OIG explained.
Broader Implications and Concerns
Overpayments within Medicare Advantage plans have been a persistent concern for regulators and lawmakers. Earlier this year, the Medicare Payment Advisory Commission (MedPAC) estimated that the federal government could overpay MA plans by a staggering $76 billion by 2026.
One major contributor to these overpayments is “upcoding,” a practice wherein insurers escalate risk ratings to secure additional payouts. MedPAC’s analysis indicated that coding intensity significantly contributes to overpayments, with fraudulent or inaccurate diagnoses being a primary factor.
Interestingly, MedPAC also noted that Medicare Advantage plans often document diagnoses more comprehensively compared to traditional Medicare plans, which can sometimes inadvertently lead to overpayments.
Recommendations and Future Actions
In response to these findings, the OIG has recommended that CMS implement policies to prevent MA plans from submitting acute stroke diagnoses that lack support from concurrent inpatient or outpatient hospital data. As of now, CMS has not explicitly expressed agreement or disagreement with this recommendation.
Addressing these overpayments is crucial to ensuring the integrity and sustainability of Medicare Advantage plans. Stakeholders across the healthcare spectrum, including policymakers, providers, and insurers, must collaborate to rectify these discrepancies and uphold the trust placed in the system by beneficiaries. For more information, you can view the full report Here.
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