The Biggest Medicare Advantage Stories of 2018

Do You Know Them All?
1.DC Federal court threw out the 2014 payment rule. 

No one’s talking about it, but CMS is without statutory authority to pursue all but the most egregious cases of risk-coding fraud. The eventual enforcement blowback is going to be something to see. Until then, most MAOs are talking a good game about compliance,  but it's pretty much open season for risk-coding until CMS' appeal is heard.

2. CMS allowed Medicare Advantage Organizations (MAOs) to offer home care services and even increased everyone’s capitation slightly to cover for it.

However, less than 3% of plans decided to offer the services, the rest deciding to pocket the extra capitation. As national service providers organize, expect the number of plans offering home care services in increase---but not by as much as CMS thinks. The extra capitation is better spent on marketing than new services. Because of this, don't expect CMS to increase capitation to help pay for a new benefit ever again.

3. Step edits for Part D meds allowed under Medicare Advantage.

No matter how you try to shine it, it’s another unfunded labor mandate for clinicians and the organizations for which they work. And it won’t save a nickel.

4. The Federal government goes all in on Medicare Advantage.

From the decisive language change seen in the yearly Medicare guide sent to all beneficiaries to CMS direct marketing Medicare Advantage plans and insiders jumping on the boards of MAOs---it’s clear that the Federal Government wants out of the insurance business and that private insurers are happy to take up the slack. Will they be so happy when the dollars tighten?

5.CMS approves extrapolation as part of improved compliance enforcement.

Does your audit suggest you over-coded by 20%? Then you must pay back 20% of all your payments during the time period in question, not just the payments associated with the charts reviewed.  This rule change has the potential to make a huge difference in enforcement, once the statutory issues mentioned above are worked out. In fact, the difference extrapolation could make could be so huge that it’s doubtful that it will ever be used as anything but a threat.

Next week, I revisit my 2018 predictions for accuracy and make my picks for the biggest Medicare Advantage surprises for 2019. (spoiler alert---I did pretty good!)

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