The Office of Inspector General has released a four-phase oversight strategy for managed care organizations, including Medicare Advantage plans, and says it will address key risk areas and improve its partnerships with these organizations.
The strategy comes as MA accounts for a growing share of the Medicare market. Half of Medicare enrollees were enrolled in MA in 2022.1 That same year, half ($403 billion) of federal Medicare funds went into MA plans, up from 19% in 2007.1 To ensure proper use of taxpayer funds, OIG will “conduct rigorous oversight of managed care plans while also closely coordinating with the same plans to fight fraud, waste, and abuse.”1
OIG’s new strategy encompasses four components that consider the risks associated with different phases of managed care programs and how they affect Medicare and Medicaid.1 The components include:
- Plan establishment and contracting. This phase focuses on activities that occur when a plan is established or a contract is renewed. OIG notes that if plans provide inaccurate information or fail to adhere to the contract during this phase, adequate care may not be provided.
Focus areas for this phase may include review of contracts with the state or CMS, plan benefit design, establishment of plan service area, and accuracy and integrity of plan bids.
- Enrollment. This phase focuses on the enrollment process, and OIG notes that enrollees could be at risk if organizations use aggressive marketing or violate marketing guidelines, such as by providing incorrect information.
Focus areas may include marketing, agent or broker activities, eligibility determinations, and accuracy and use of enrollment data.
- Payment. This phase focuses on payments made by CMS and states to plans, as well as plans’ payments to providers. OIG notes the risk for fraud, waste and abuse if plans misreport the health status of enrollees or make improper payments to providers.
Focus areas may include risk adjustment, payment accuracy, medical loss ratio, and the value-based care or other alternative payment mechanisms used by plans, states and CMS under managed care programs. OIG will also continue looking into providers that engage in fraud in fee for-service Medicare and Medicaid and also provide services in managed care networks.
- Services to people. This phase focuses on ensuring enrollees have adequate access to high-quality services. OIG notes a potential risk to enrollee access if plans create barriers to certain services.
Focus areas may include network adequacy, ineligible or untrustworthy providers, coverage determinations, whether enrollees are receiving care that meets clinical guidelines, and fraud schemes that cross multiple plans and/or federal health care programs.
The strategy is intended to reinforce OIG’s goals of promoting access to safe, effective and equitable care for people enrolled in managed care; providing comprehensive financial oversight and promoting a culture of compliance; and promoting data accuracy and data-driven decisions to ensure resources are used appropriately.
Plans that continue to ensure compliance and improvements in these four areas will be on track for successful partnerships with OIG during periods of increased oversight and beyond.
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References
- Oversight of managed care for Medicare and Medicaid. HHS-OIG. August 2023. https://oig.hhs.gov/reports-and-publications/featured-topics/managed-care/Strategic_Plan_Managed_Care.pdf
