OIG Issues New Medicare Advantage Compliance Guidance
The Office of Inspector General (OIG) has published its long-awaited Medicare Advantage Industry Segment-Specific Compliance Program Guidance (MA ICPG). It is the first significant change in the Medicare Advantage (MA) program in over 25 years. The new guidance indicates the dramatic growth, complexity, and heightened regulatory scrutiny of the MA program and also the increased compliance expectations for not only the MA plans but also health care providers and other participants in the program.
Although the MA ICPG is voluntary and nonbinding, it identifies compliance risk areas and gives detailed and practical recommendations that will help minimize fraud, waste, and abuse. Importantly, OIG makes clear that providers participating in MA networks are now firmly within the compliance spotlight.
Higher Supervision of Providers and Third Parties
One of the main topics of the guidance is enhanced control over the First Tier, Downstream, and Related Entities (FDRs), including providers and their subcontractors. OIG reiterates that MA plans are ultimately responsible for the actions of their FDRs and encourages plans to implement more proactive monitoring, auditing, and compliance oversight practices.
The guidance suggests dedicated oversight teams for providers, including oversight of network adequacy, quality data and analytics, coding audits, and utilization management case logs.
OIG also urges MA plans to investigate any suspected misconduct internally and refer the misconduct to law enforcement where necessary. Consequently, providers are likely to receive increased scrutiny of operations and of any downstream subcontractors, including IT providers and overseas partners.
Risk Adjustment and Accuracy of Documentation
OIG highlights risk adjustment as a high-risk area, citing concerns over:
- Submission of unsupported diagnosis codes
- Upcoding or overstating condition severity
- Incomplete or inadequate documentation
- Use of automated electronic medical record (EMR) prompts that encourage physicians to add diagnoses unrelated to patient care.
The guidance recommends that MA plans implement sophisticated data analysis, such as artificial intelligence applications, to determine the quality of data submitted by providers. Such steps will result in a higher number of requests for medical records and more audits. Providers having good documentation practices, diagnosis validation processes, and internal compliance control will be in a better position to respond to these reviews.
Provider Directory Accuracy and Network Adequacy.
The MA ICPG further discusses the lack of network adequacy and provider directory accuracy, warning that administrative sanctions can be imposed on the shortcomings of MA plans in these areas. Greater adherence would be beneficial since it would increase chances of participation in the network and enhance patient access.
Simultaneously, the providers can face tighter contractual requirements regarding the timely update of the roster. This remains a risk area because failure to meet the directory accuracy requirements has led to payment reductions and claim denials in the past.
Marketing
The dominant area of enforcement is marketing. Although much of the guidance is directed at MA plans and marketing organizations, OIG cautions against arrangements where providers are compensated to refer patients to certain MA plans. The guidance uses the example of OIG’s 2024 Special Fraud Alert on MA marketing, highlighting existing issues with provider participation in inappropriate MA-related marketing.
Next Steps
The new guidance issued by OIG clarifies that compliance responsibility in the MA program goes far beyond the health plans. Providers should expect more frequent audits, increased data requests, and additional compliance requirements from MA plans.
Providers can manage risk by enhancing internal controls, improving documentation quality, and paying close attention to relationships with subcontractors. This will help them navigate the increasingly regulated Medicare Advantage environment.
