BC Advantage - 2020 Issue 9

Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately

We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began by stating their desired outcomes, which include healthier beneficiaries, lower costs, better care, and a more efficient system and that the three main areas for concern include:Quality services (network adequacy, denials, and appeals)Federal funding (fraud, risk adjustment validation audits (RADV), and rates)Data integrity (security, adequacy, and compliance)The OIG...

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