Winds of Change are Blowing for Some Medicare Advantage Plans

Rumors persist of possible leadership changes at some Medicare Advantage plans in the mid-South region.

From where I sit, which is very close to the Gulf of Mexico, there are apparent winds of change blowing through the Medicare Advantage (MA) payers. 

This seems to be a direct result of what has been ongoing – and, hopefully soon, more aggressive actions will be taken by the U.S. government, specifically the U.S. Department of Justice (DOJ) and the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG), in their audits of MA plan activities and processes. There was a recent New York Times article by Reed Abelson and Margot Sanger-Katz, titled The Cash Monster Was Insatiable:  How Insurers Exploited Medicare for Billions, which aptly points out, and I quote, “most insurers in the program have been accused in court of fraud.” 

Mark my words: the payers have most definitely taken notice. While the government continues to scrutinize the audit processes with the payers, the payers themselves almost seem to be doing preemptive damage control. Healthcare organizations have noticed total sweeps of leadership teams. Those individuals you’ve dealt with for many years in some cases have been shown the door and replaced with entirely new teams.   

These old and new teams that I’m talking about are made up of people such as your provider representatives, payment integrity representatives, contracting representatives, etc. These new teams at various payers appear, in some cases, to be making some attempts at collaboration with providers. Don’t misunderstand me here.

In no way has the system suddenly been fixed. Just note that if you are noticing efforts to collaborate, be receptive to these efforts, because in the end, we all want to get our audit denial inventory resolved and receive the reimbursement we are rightfully due.

Speaking of inventory, let’s move on to prepay and post-pay audits – they’ve been affecting all of us for years, but never before like they are now. With Humana clinical audit mail, you all know that it comes directly from Humana. Alternatively, a payer such as UnitedHealthcare (UHC) has all of its clinical audit mail coming from an array of third-party auditors. Humana also uses third-party auditors, but behind the scenes, so that you never see who they are. Interestingly enough, many of Humana’s auditors are some of the same that UHC is using, including some of UHC’s companies, such as OPTUM – how crazy is that? Is it me, or does that feel sketchy? And don’t even get me started on the risk adjustment audits, like the ones covered in the New York Times article. 

Several years ago, I asked one of our largest payers (Humana) if any reporting was available to show what they had as our audit inventory. We just wanted to try and reconcile it next to what we showed as unresolved disputes. At first, I received an adamant “no.” But if you know me, and some of you do, I did not let up on the request. To me, this was totally a transparency issue. So, I kept asking. I wanted a monthly spreadsheet from their system that showed every audit for every one of our facilities, for a rolling 18 months – and on it, I wanted all the claim and patient information, associated dollars, and the status of the audits in their system (and by status, I meant audit status, or dispute status, where is it in your process?) After several tries, I was finally told that they could run something out of their system and email it to me. Flash forward, over time, we were able to get the same information from UHC on a vendor activity report. 

Back to my earlier point of Humana’s auditors. If you don’t know who Humana is using on a particular audit or account, how can you compare your vendor activity report data to the other payers? It would be nice to know how they are performing, comparatively speaking. For example, if Cotiviti is not getting something right with one particular payer, but seems to be performing okay on another payer, how is that fair if it’s, let’s say, the exact same DRG – like DRG 190 for COPD with an MCC? Hopefully, these are some of the things that the DOJ or the HHS OIG might take notice of in their audits.

So, my friends, there is still more work to be done; there’s still lots of money on the table. If you are not already asking for vendor activity reports, you need to do it sooner rather than later, so that you can reconcile your prepay and post-pay audit activity. In the meantime, stay strong and stay vigilant.

About the author: Jennifer Bartlett is the systems coordinator of clinical audits and disputes at Infirmary Health in Mobile, Alabama.