In recent news, the healthcare industry has been abuzz with significant developments that carry vital lessons for Medicare Advantage plans, particularly in the areas of compliance and risk assessment. These developments underscore the importance of proactive compliance monitoring and the serious implications of failing to adhere to regulatory standards.
The Case of Cigna and the Importance of Accurate Data Reporting
A notable case involves Cigna, a major healthcare payer, which settled with the Department of Justice for $172 million over False Claims Act violations. Cigna allegedly submitted inaccurate patient diagnosis data to the Centers for Medicare & Medicaid Services (CMS), impacting payments received and raising serious compliance concerns​​.
CMS’s Role and the RADV Program
Medicare Advantage overpayments have become alarmingly problematic in the private payer program. The USC Schaeffer Center for Health Policy & Economics estimated that Medicare Advantage overpayments may exceed $75 billion in 2023. Keeping this in mind, the CMS is increasing its Medicare Risk Adjustment Data Validation (RADV) program to identify improper overpayments by confirming that diagnoses submitted by Medicare Advantage plans for risk adjustment accurately reflect beneficiaries’ health statuses.
This program is a critical aspect of CMS’s strategy to maintain the integrity of Medicare Advantage plans and ensure that funds are appropriately allocated based on accurate and truthful data.
Compliance and Risk Mitigation
The recent Cigna case highlighted the need for Medicare Advantage plans to focus on risk mitigation assessments to avoid similar compliance issues. It serves as a stark reminder that routine risk and compliance assessments are not just optional but essential for the smooth operation of Medicare Advantage organizations​​.
Proactive Measures for Compliance
In light of this settlement, it’s crucial for Medicare Advantage organizations to assess their compliance actions regularly. This includes conducting annual risk assessments and ensuring that data submitted for risk adjustment is accurate and verifiable​​​​. Proactively assessing data and compliance measures can place organizations in a better position to respond to any potential investigations or audits​​.
For operation and compliance professionals in US health plans, these developments indicate the evolving landscape of healthcare compliance. Staying ahead in this domain requires a continuous commitment to accurate data reporting, regular compliance checks, and a proactive approach to risk assessment. Healthcare organizations can avoid potential pitfalls and strengthen their operational integrity and efficiency by learning from these recent cases and staying vigilant.
Don’t wait for a compliance issue to get out of hand before you address it. Contact us or call 1.408.850.2235 to learn how Inovaare can help your health plan stay ahead in compliance and risk management, ensuring operational excellence and 360-degree compliance oversight.