Medicare Compliance & Reimbursement

Report #1: Medicare doesn’t require MA plans to use a claim denial indicator on denied claims, and that makes it a challenge to track such denials. So concludes an HHS Office of Inspector General (OIG) report released on March 2.

“Adjustment codes are not a definitive method for identifying denied claims in the MA encounter data. The descriptions for some adjustment codes are too vague to clearly identify whether the MAO denied payment for a service,” the OIG maintains.

“CMS’ MA payment group raised concerns about the potential burden on MAOs of requiring a denied-claim indicator on their encounter records,” the OIG says in the report at https://oig.hhs. gov/oei/reports/OEI-03-21-00380.asp.

Report #2: The Government Accountability Office (GAO) examined just what supplemental benefits MA plans are offering. In 2022, the vast majority offered vision and hearing at 98 percent and 94 percent, respectively. But only 17 percent offered in-home support services and a sparse 6 percent offered support for enrollees’ caregivers, despite both benefits being allowed since 2019.

But: That data is a little fuzzy, because of apparent misunderstandings about plans’ requirements to report encounter data for supplemental benefits. Centers for Medicare & Medicaid Services (CMS) officials “told GAO that the inclusion of supplemental benefits in this requirement is clear, noting the guidance does not differentiate between supplemental and Original Medicare benefits,” the GAO notes. But “officials from three MA organizations told GAO they are not required to submit encounter data for some or all supplemental benefits and therefore do not do so.”

The GAO urges CMS to clarify the requirements with the MA plans, according to the report at www.gao.gov/products/gao-23- 105527.