OIG Issues Report on Effectiveness of CMS Capitation Payment Policies in Preventing Payments for Deceased MA Beneficiaries.

Date posted: November 3, 2017

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released a report regarding the Centers for Medicare and Medicaid Services (CMS) policies and procedures related to Medicare Advantage (MA) program capitation payments for deceased beneficiaries.  The Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) requires CMS to establish policies and procedures that prevent payments for services rendered to deceased beneficiaries.  The OIG evaluated capitation payments from 2012 through 2015 to determine CMS’s policies and procedures’ effectiveness in preventing capitation payments to deceased beneficiaries and in recouping improper payments.

The OIG reported the following findings:

  • CMS policies are generally effective in preventing capitation payments to MA organizations for Medicare Parts A and B services;
  • During calendar years 2012 through 2015, CMS made 1.8 million adjustments to capitation payments upon receiving updated beneficiary date-of-death information;
  • CMS recouped $2.96 billion from MA organizations for payments made to deceased beneficiaries;
  • CMS failed to recoup all improper payments, leaving roughly $2.4 million from 1,817 capitation payments made for 978 beneficiaries; and
  • The non-recouped improper payments amounted to .0004 percent of the total capitation payments to MA organizations, and .08 percent of the total adjustments made upon receiving updated dates of death.

The OIG recommended the following:

  • CMS should attempt to recoup the $2.4 million in capitation payments made to MA organizations on behalf of deceased beneficiaries;
  • CMS should implement system enhancements to identify, adjust, and recoup improper capitation payments in the future.

CMS concurred with both of these recommendations and described corrective actions that it had implemented.

The OIG Report is available at:

https://www.oig.hhs.gov/oas/reports/region7/71605087.pdf.

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