Fierce Health Payer December 12, 2019
Robert King

A federal watchdog is concerned Medicare’s rules have enabled Medicare Advantage (MA) plans to make patients appear sicker than they are to get higher payments.

A report issued Thursday by the Department of Health and Human Services Office of Inspector General (OIG) questions the use of chart reviews by MA plans. OIG is concerned that such chart reviews can be used by plans to get higher risk-adjusted payments from the Centers for Medicare & Medicaid Services (CMS).

Chart reviews allow MA organizations to add or delete diagnoses in their encounter data “based on reviews of patients’ records,” the report said. However, a chart review could let MA organizations circumvent CMS’ face-to-face requirement, which mandates a physician or practitioner has seen the patient....