Medicare Advantage Compliance

In recent news, the healthcare industry has been abuzz with significant developments that carry vital lessons for Medicare Advantage health plans, particularly in the areas of compliance and risk assessment. These developments underscore the importance of proactive compliance monitoring and the serious implications, including the heightened possibility of being exposed to RADV Audits for failing to adhere to regulatory standards. 

Importance of Accurate Data Reporting 

Recently, a major U.S. healthcare payer settled with the Department of Justice over False Claims Act violations. Allegedly, the health plan 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 Audits 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. To combat this serious issue, CMS is increasing its Medicare Risk Adjustment Data Validation (RADV) program to identify improper overpayments by confirming that diagnoses submitted by Medicare Advantage health 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 

Medicare Advantage health plans must focus on risk mitigation assessments to avoid compliance issues. Routine risk and compliance assessments are essential for the smooth operation of Medicare Advantage organizations​​. 

Proactive Measures for Compliance 

In light of these issues, 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 operations and compliance professionals in U.S. health plans, these developments indicate the evolving landscape of healthcare compliance. Staying ahead 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 recent settlements 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.