Content area
Abstract
The Centers for Medicare & Medicaid Services (CMS) is currently implementing new programs to address potential fraud and abuse issues and recoup overpayments across providers and health plans. CMS is looking to recoup money from payer plans where claims submitted are not supported by documentation in the patient's medical record. CMS wants to identify the accuracy of Medicare Advantage (MA) data, determine if it is measurable, and find out whether any overpayments have been issued. One step that can be taken is submitting accurate resident assessment protocol summary data. Another step MA plans can take is to focus audits on primary care providers and specialists who only report diagnoses assigned to specific hierarchical condition categories once per year. One final thought: remind physicians to encourage their MA patients to come in for their annual physical exam. This extra step would allow the additional focus on patients with chronic conditions annually at a minimum.