24-June-2015

The risk-score documentation of Medicare Advantage (MA) health plans will face a substantial uptick in scrutiny in the coming months. An article in the June 18, 2015 edition of Medicare Advantage News observed that "an assortment of federal government agencies, nonprofit organization researchers and private-sector whistleblowers all have dived deeply into MA risk adjustment in the past year." While there is room to reach different conclusions, the Government Accountability Office (GAO) found $12 billion worth of "unwarranted" government outlays related to MA risk scores, and the National Bureau of Economic Research (NBER) attributed $10 billion of excess government payments to MA risk-adjustment problems.

In the piece, Mike Adelberg, senior director for FaegreBD Consulting, advised MA officials to audit their own operations in anticipation of more regulatory vetting.

"MA organizations should look at their policies and procedures and make sure their documentation is in order and they're investigating any overpayment or miscoding allegations."

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