Analysis of 17 OIG reports reveals compliance blueprints for Medicare Advantage and provider organizations

Part 1 of an ongoing series

By Jason Jobes

Today I am starting a series on my analysis of the 17 Medicare Advantage OIG reviews released from 2022-2023. Given the rule released on extrapolation earlier this year hopefully we can use some of the findings to springboard improvement.

Thanks for reading. If you find this type of content helpful, please continue to like, share, or comment. If you have questions feel free to to send me a direct message (my email is below)

Background and project scope: I reviewed all of the 17 OIG reports released from 2022 to present. I have provided a link to those below. Given the impact that these reports may have moving forward, I wanted to see where the risk areas exist and how organizations can help protect themselves from excess risk.

Note that while MA payers have been the focal point, there is still a significant number of organizations in full risk arrangements that may ultimately be subjected to penalties.

For the related graph (see associated picture), I looked at the findings from the 14 OIG reviews targeting high risk areas. These include acute stroke, acute heart attack, major depression, vascular claudication, embolism, miskeyed diagnoses, and more. CMS ultimately zeroes in on these conditions because there is a perceived higher amount of inappropriate (which doesn’t mean intentional) capture of these conditions. They will then look at these conditions and seek to validate them from chart reviews.

As someone with a predictive analytics background, it is easy to see that CMS is clearly on to something. In these 14 reviews they looked at 3,545 conditions. Of those, they were only able to validate 1,023 of them. This means that 71% were not deemed to be valid, and therefore an overpayment occurred.

The dates of service for these reviews ranged from 2015-2017. As an industry we have come a long way since then. Hopefully your organization, be it payer or provider, is looking at this information and using it to continue to help inform clinicians how to ensure they are appropriately addressing conditions. Many of these represent wording as simple as “history of” to ensure an acute episode is not being captured.

In future installments I will share more specifics about the impacts that this may have financially on organizations.

Link to the OIG reports-

Link to my survey asking how your organization handles OIG high risk diagnoses-

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