OIG releases MA compliance program guidance

After releasing its General Compliance Program Guidance in 2023, the Office of Inspector General (OIG) is continuing to deliver supplemental guides geared toward specific subsectors of the healthcare industry. Released on February 3, the Medicare Advantage (MA) Industry Segment-Specific Compliance Program Guidance (ICPG) details several key risk areas relevant to the MA program and provides recommendations to various parties to mitigate these risks.

This ICPG is the first update that the OIG has made to this category of guidance since 1999. The agency decided to revisit this guidance in response to the growing popularity of managed care and its recent findings related to the MA program. While the ICPG primarily provides instructions to MA Organizations (MAO), it also offers insights to healthcare facilities and other entities engaged with the program.

The ICPG highlights the following key ongoing risk areas that require action from MAOs and other parties:

• Access to care
• Marketing and enrollment
• Risk adjustment
• Quality of care
• Oversight of third parties
• Compliance programs within vertically integrated organizations and other ownership structures
• Submission of accurate claims

Revenue integrity professionals should take note of the OIG’s emphasis on risk adjustment. In recent years, the agency’s audits have revealed problematic behaviors from MAOs, providers, and others involved in the risk adjustment process. This includes healthcare organizations submitting diagnoses that were not supported by the medical record to inflate MAO payments made under risk-sharing or other arrangements, as well as conducting in-home health risk assessments to generate additional unsupported diagnoses. The OIG encouraged MAOs to implement additional oversight of the risk adjustment process, so facilities should prepare for additional record requests and audits in the future.

Healthcare organizations should also consider the OIG’s focus on third party oversight. The agency urged MAOs to consider implementing tailored compliance processes for healthcare providers that serve as first tier, downstream, or related entities (FDR). For example, if a plan delegates functions to an FDR (e.g., independent practice association), it can establish an oversight team to monitor the provider and require reports. In this instance, the MAO’s oversight efforts could include network adequacy, quality data and analytics, coding audits, and utilization management case logs.

Overall, the ICPG calls on MAOs to increase their voluntary monitoring efforts and go beyond standard compliance program requirements from CMS. As the OIG continues to apply pressure to MA plans, facilities must ensure their internal processes and procedures are sound ahead of potential oversight and compliance policy enhancements.

Revenue integrity professionals can view the complete guidance document to learn more about the seven risk areas for the MA program, as well as access relevant links and resources to assist with compliance efforts. The OIG noted that it may update the ICPG periodically to address new risk areas and compliance measures.