Attention Medicare Advantage Plans (and Consultants): They’re Coming!

They’re coming.

They’re coming. CMS recently announced its plan: the long-threatened blitz of a government auditor army. 50 times as many as before. 2,000 in all by September. The biggest and fastest surge CMS has ever had. They’ll look at every single MA plan. Not just a skim of a few dozen players. Everybody, over 500 plans. And this time, they’ll look harder and deeper. Not just a quick surface touch, of say 20 charts. No, this time it will be way more. Like 200. Using the latest, most powerful AI and data analytics tools.

The Numbers.

You’ve heard the numbers. Claimed risk adjustment overpayment ranging from 20 to 40%. Up to between $40 and $120 billion a year. With the 6-year recoupment period, who knows how much that might mean in defense audit costs, extrapolations, and clawbacks? Even whistleblower suits, False Claims, in the worst cases.

The Star Ratings.

Finally, there are the Star Ratings: 4 out of 5 plans got 4 or less. Resulting in real, big dollar, missed opportunities. To earn Quality Bonus Payments, Benchmark Increases, and rebates. Or even worse, getting dinged by poor performance penalties.

A new reality.

Things have changed. And you know you can do better. But you’ll need help. To prepare. But especially in the post-audit phase. In corrective action plans, remediation.

What are you doing about it?

CMS will undoubtedly ask, what are you doing to make things better? To get more complete, accurate diagnoses codes?

Let us help you get physician buy-in.

We can help. I’ve spent my entire career working with physicians, medical practices, and their staffs. Working with and for clinicians across the full range of specialties and practice settings. I've served inside a medmal insurance company, as general counsel at various healthcare businesses, and as a compliance officer working through various integrity agreements. I have designed, implemented, integrated and administered tailored compliance programs.

Why not look at what you can do to get the doctors' cooperation, buy-in? Rather than continuing in an adversarial, contentious, reactive, cat-and-mouse game? Better to work affirmatively, to be more like the elite 1%, the 5-Star Rated plans.

The new reality will only be answered by a solution that gets directly at the source: better provider relations. Genuine engagement, true collaboration. Because they’re the ones who generate and control the diagnoses that go into the patient’s chart. Shouldn’t you actively engage with them, collaborate, to answer CMS’s call for cleaner, more accurate diagnoses? Along with the likely improvement of nearly every other key metric?

Let’s talk about how we can help. To build physician engagement, foster and incentivize collaboration, to make your plan the most secure, best it can be.

Reid Pearlman, JD, CCEP is an independent healthcare compliance consultant based in Atlanta, Georgia. He can be reached at Reid@MyComplianceOfficer.net.

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