Turning Up the Heat on HRA-Based Diagnoses in MA

Déjà Vu All Over Again, or Will There Be Action as Well as Lights and Cameras?

By James Gutman - January 29, 2016

Are you ready for another round of efforts to stop alleged abuse of home health risk assessments (HRAs) for diagnosis and payment purposes in Medicare Advantage (MA)? Well, ready or not, it is coming this year — and from multiple directions. And the chances of something getting done this year are higher than in the past few years, observers tell AIS, when CMS has proposed but not finalized curbs on HRAs. The agency then struggled amid such complexities as what the definition of an HRA is, how to require clinical follow-up of HRA findings when the patient has to allow it to occur and what should be done to avoid “throwing out the baby with the bathwater” since all the parties seem to agree that HRAs have value.

What is different this year? For one thing, says John Gorman, executive chairman of consulting firm Gorman Health Group, LLC, “An election year is the perfect time to do this.” He and others point to 2016 being the last year of a two-term presidential administration, meaning that it’s now or never for political appointees to fulfill their remaining policy goals before their successors move in. Gorman, acknowledging he’s predicted this before, forecasts that this year CMS finally will “raise the bar” on HRAs in MA by requiring some sort of clinical follow-up or “another form of code verification” before allowing use for payment purposes of patient diagnoses obtained solely from HRAs.

Nor is it just CMS that’s worried about current or potential future abuse of HRAs in MA. The Medicare Payment Advisory Commission (MedPAC) on Jan. 14, and with only one dissenting vote among its 17 commissioners, adopted a staff proposal that would exclude for MA risk-adjusted payment purposes diagnoses obtained just from HRAs without any evidence of clinical follow-up. Boosting its desire to act were new data from MedPAC researchers that show payments to MA plans based on Hierarchical Condition Category (HCC) codes found just in home visits were soaring along with a big boost in the number of HRAs administered.

And then there is the overhang of outside developments. Now, for instance, a good number of pending whistleblower lawsuits allege MA upcoding, some of it related to HRAs. And the Center for Public Integrity, a nonprofit government-accountability and journalism organization that has its articles picked up by many large newspapers, continues to add stories to a series it wrote in 2014last year about alleged risk-score abuses in MA.

What do you think is likely to happen this year on MA HRAs? And what do you think should happen if the goal is basically to eliminate fraud but without killing off HRAs, which several MedPAC commissioners made a point of saying not only have value in MA but even should be used more frequently than they are in Medicare fee-for-service? How do you solve the problem without throwing out the baby with the bathwater? Or is the water already so hot that there is no time to cool it down?

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