OIG Identifies Unnecessary Denials, Delays by Medicare Advantage Plans

May 03, 2022 - The Medicare Advantage program has proven quite lucrative for commercial health plans over the years, but a federal agency is calling into question whether certain business practices are leading to unnecessary revenue.

OIG Calls Out Unsavory Medicare Advantage Plan Practices

Medicare Advantage plans have incorrectly denied or delayed prior authorizations or payment requests and, in doing so, have accrued unwarranted revenues, according to a report from the Office of Inspector General (OIG).

OIG conducted the investigation because there was a possibility that Medicare Advantage plans might use the capitated payment model to boost revenue by denying access to coverage. The office acknowledged that most payment requests receive approval, but referenced data from CMS indicating that Medicare Advantage plans may issue inappropriate denials.

To test whether Medicare Advantage plans were misusing the payment denial process, OIG relied on data from 15 of the largest Medicare Advantage organizations. They took a sample of 250 denied prior authorizations in addition to the same number of payment denials. The requests and denials occurred between June 1 and June 7, 2019.

OIG found that 13 percent of the denied prior authorization requests would have been approved under fee-for-service Medicare coverage. For payment requests, 18 percent of those that were rejected would have been approved under fee-for-service Medicare. READ MORE

UPMC, Pitt Able Predict Brain Injury Outcomes with Machine Learning

According to researchers from UPMC and the University of Pittsburgh School of Medicine, advanced machine learning can be used to predict outcomes in patients with severe traumatic brain injuries (TBI).

In a study published in Radiology, the researchers created a deep learning model that analyzes admission CT scans and clinical data from TBI patients to predict six-month mortality and other unfavorable outcomes. The researchers noted that it typically takes two weeks for patients with severe TBI to emerge from a coma, but these patients are often taken off life support within 72 hours after hospital admission.

The model was trained and validated using two patient cohorts: one of 537 patients treated for severe TBI at UPMC and another of 220 patients taken from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) consortium.

The model’s performance was evaluated against the International Mission on Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model and the predictions of three neurosurgeons. The model accurately predicted patient mortality risk and unfavorable outcomes at 6 months following the traumatic incident, and it outperformed the predictions of the neurosurgeons. READ MORE

Advanced Bundle Payments Drove Down Medicare Episode Payments

The CMS Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model reduced Medicare fee-for-service episode payments for both surgical and medical episodes, according to a new report for CMS prepared by The Lewin Group.

For all clinical episodes, the BPCI Advanced Model reduced average episode payments by $743 per episode, or a 2.7 percent decline from the baseline mean, the report found. The reduction was higher for surgical episodes, which saw a 4.5 percent reduction from the baseline mean, amounting to $1,353 per episode. The model reduced payments by 2.2 percent for medical episodes, or $564 per episode. Payment changes were similar among hospitals and PGPs.

CMS launched the BCPI Advanced Model in October 2018, building upon the original BCPI initiative. The BCPI Advanced Model requires providers to assume more financial risk for clinical episodes. The model aims to test if linking payments for an episode of care can reduce Medicare spending while maintaining or improving care quality.

Under the model, participants are financially accountable for the cost and quality of healthcare services during a clinical episode, which ends 90 days after a discharge or procedure. Episode payments are then compared to the episode initiator’s risk-adjusted target price. Participants receive a reconciliation payment if the episode payment is below the target price. But if episode payments are above the target price, providers must repay Medicare a portion of the financial losses. READ MORE

Systemic Racism Limiting Access to Mental Health Services

Despite happening nearly a hundred years ago, the nation is still seeing the impacts of redlining and other forms of systemic racism, with recent data showing that redlining has resulted in present-day limits on patient access to mental healthcare.

The data, published in JAMA Network Open by researchers from the George Washington University Milken Institute of Public Health, found that redlining caused nearly a 20-fold disparity in the mental healthcare workforce in Greensboro, North Carolina, a city with a noted mental healthcare provider desert.

In Richmond, Virginia, which also has longstanding provider shortages, the mental healthcare workforce disparity was six-fold, the researchers said.

These findings come as the healthcare industry continues to focus on health equity and acknowledge the role that historical systemic racism, like redlining, has played in current disparities. READ MORE

Regional NY Hospital Set to Enable Remote Physical Examinations

A new partnership between Rochester Regional Health and TytoCare will make the company's artificial intelligence-powered tools available to the health system's clinicians, enabling them to provide remote physical examinations to patients in the Western New York region.

Per the new collaboration, Rochester Regional Health will use multiple tools and services provided by TytoCare, including TytoHome and TytoClinic, which are kits that provide consumers with various monitoring devices.

The TytoHome kit includes an exam camera, thermometer, stethoscope, tongue depressor adaptors, and more. These provide patients with tools to conduct physical examinations at home, performing total reviews of the heart, skin, ears, throat, abdomen, and lungs. Clinicians can review the exams remotely and connect with patients virtually.

The TytoClinic kit includes similar tools as TytoHome and can help turn any location into a remote telehealth clinic. Rochester Regional will use this kit in school-based and home-based healthcare settings for patients with congestive heart failure. READ MORE

Positive News for Pfizer’s Pediatric Lyme Disease Vaccine

Pfizer and Valneva recently reported positive Phase 2 pediatric data for their Lyme disease vaccine candidate, VLA15.

The Phase 2 trial, VLA15-221, is the first clinical study with VLA15 that enrolled a pediatric population aged 5–17 years old. Researchers compared the immunogenicity and safety of the vaccine candidate after administering two or three primary series doses in three separate groups.

The first group included patients aged 5–11 years old, the second group included patients aged 12–17 years old, and the third group included patients aged 18–65 years old. VLA15 was more immunogenetic than in adults for all vaccination schedules. The safety and tolerability profile observed in patients aged 5–17-years old was similar to the previously reported profile in adult participants. Researchers observed no vaccine-related serious adverse events. READ MORE