Kusserow on Compliance: Inappropriate denial of services and payments in the Medicare Advantage program

In an update to its Workplan, the HHS office of Inspector General (OIG) added a new project in June. The OIG Office of Evaluation and Inspection will be reviewing and evaluating the question of inappropriate denial of service and payment in the Medicare Advantage program. Medicare Advantage Plans must cover all of the services that original Medicare covers. Capitated payment models are used for these plans. It is based on payment per person rather than payment per service provided. A central concern about the capitated payment model used in Medicare Advantage is that there may be an incentive to inappropriately deny access to, or reimbursement for, health care services in an attempt to increase profits for managed care plans. There have been questions raised as to whether some of the plans may be inappropriately denying service claims as a means to increase their profits.  The OIG plans to conduct medical record reviews to determine the extent to which beneficiaries and providers were denied preauthorization or payment for medically necessary services covered by Medicare. To the extent possible, we will determine the reasons for any inappropriate denials and the types of services involved.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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