Compliance Today (December 2020)

A recent report^[1] released by the U.S. Department of Health & Human Services Office of Inspector General found that billions in Medicare payments were paid out for risk assessments performed by third parties, often in-home assessments, which may have exaggerated risks and not resulted in more care.

Christi Grimm, principal deputy inspector general of the Office of Inspector General, published an opinion piece to accompany the report,^[2] in which she pointed out that government agencies such as hers were aware of the issue and would be scrutinizing risk adjustments going forward. She wrote that risk adjustments were necessary in order to differentiate care between different beneficiaries, but if those assessments were profit driven, as opposed to care driven, then providers could face investigations and possible enforcement actions.

“Risk assessments that generate diagnoses for payment purposes, but result in no follow-up care raise serious concerns,” Grimm wrote. “Ensuring beneficiaries receive the care they need should be front of mind for executives as they design risk assessment programs with an eye to quality of care and better care coordination. Failing that, executives should know that government agencies will scrutinize risk adjustment for abuse.”

1 Christi A. Grimm, “Billions in Estimated Medicare Advantage Payments From Diagnoses Reported Only on Health Risk Assessments Raise Concerns,” U.S. Department of Health & Human Services, Office of Inspector General, September 2020, https://bit.ly/33uUGvn.
2 Christi A. Grimm, “Medicare Advantage should not ‘game the system’ but prioritize patient care, honest billing,” Healthcare Dive, September 23, 2020, https://bit.ly/34h0k5Q.

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