Increasing government oversight of Medicare Advantage (MA) plans and sharing data with nursing homes could reduce claim denials and burdens associated with such plans, industry leaders say. have been arguing for many years. Now, a report released Thursday by a parliamentary advisory panel backs up that view by revealing how registrants are captured in the data.
The Medicare Payment Advisory Commission (MedPAC) report takes a closer look at the current state of MA patient data and is the latest move toward better understanding and oversight of such plans. This is due to the expansion of Medicare Advantage in nursing homes and other care settings in 2024.
MedPAC compared data sources on skilled nursing care utilization for MA enrollees: Minimum Data Set (MDS) assessments and MA enrollees with SNF encounter data records.
Encounter data is considered important to the Medicare program and provides program oversight for MA enrollees, according to the report. This data is also intended to simplify the administration of the MA program and to inform and generate new policies.
Overall, MedPAC researchers said data on service use among MA enrollees is incomplete but improving over time. Committee members were interested in whether the missing data was random or due to a systemic problem.
Scrutiny with data
Approximately 10% of MA encounter data to measure service utilization across the continuum of care for MA enrollees was missing. However, they noted that relatively high data completeness for one service category is not an indicator of complete data across all service categories.
“If the data is missing at random, 10% may not be that much of a problem. It matters when it is systematically lacking,” said MedPAC board member Dr. Lawrence Cassarino.
MedPAC committee member Dr. Tamara Konetzka expressed surprise that MDS does not fully understand MA enrollee services. It has been used for many years to identify her SNF and home health utilization among MA enrollees and is used for payment as well as care planning and quality measurements.
“[SNF providers] There are many motivations for filling out data sheets for each patient. For SNFs, it is required for all residents in the facility, even if they do not have Medicare or Medicaid. It should be quite complete,” Konetzka said.
Additionally, the MedPAC report indicates that the interview data was intended to capture details of the health status and treatment of MA beneficiaries, based on meetings with clinicians.
MedPAC committee staff Stuart Hammond and Andy Johnson said the proportion of MA enrollees included in both data sources has improved over time in the nursing home sector, from 66% in 2017 to 2021. They found that it appears to have improved by up to 81%. In other words, the proportion of MA registrants is increasing. Both MDS and MA encounters are represented in the data.
However, 15% of MA SNF users are detected only in MDS data and 4% are detected only in MA encounter data. This means that there are MA enrollees that are not captured in at least one of these data sources.
“This could indicate missing encounter records, but could also have included MDS assessments for some MA enrollees receiving services not covered by Medicare. , we do not expect to have any records of such service encounters,” Hammond said. Her MA enrollees who are dually eligible are excluded from the report.
The latest in a series of MA studies
In 2022, the Centers for Medicare and Medicaid Services (CMS) announced a proposed rule that would prohibit MA plans from imposing coverage standards that are more stringent than those applicable to traditional Medicare coverage.
In January, CMS released final interoperability and preauthorization rules and proposed payment updates for MA and Part D plans. The changes outlined in the federal agency’s final rule are aimed at streamlining prior authorization and facilitating the exchange of electronic health records between health care providers and insurance plans, while also providing payer protection for denials. The aim is to further increase responsibility.
Some Congressional leaders even called for a review of insurance options in November following denials of hospitalization and delays in medically necessary care.
