More government scrutiny of Medicare Advantage (MA) plans and data sharing with nursing homes could reduce claims denials and burdens associated with such plans, sector leaders have long argued. And now a report released Thursday by a Congressional advisory body backs that view in shedding light on how enrollees are captured in data.
The Medicare Payment Advisory Commission’s (MedPAC) report dives into the current state of MA encounter data and is the latest move toward a better understanding and oversight of such plans. This, as Medicare Advantage penetration has grown in 2024 for nursing homes, among other care settings.
MedPAC compared data sources pertaining to MA enrollees’ use of skilled nursing care namely, Minimum Data Set (MDS) assessments and MA enrollees who had a SNF encounter data record.
Encounter data are considered critical to the Medicare program, according to the report, and provide program oversight for MA enrollees. This data is also meant to simplify administration of the MA program as well as inform and generate new policies.
Overall, MedPAC researchers said data on MA enrollees’ use of services are incomplete but incrementally improving. Commission members were curious if the missing data was random or due to a systemic issue.
Scrutiny through data
About 10% of MA encounter data was missing for measuring MA enrollees’ use of services across the care continuum. But, relatively high data completeness in one service category isn’t a marker of complete data across all service categories, they noted.
“If the data is missing at random, then 10% might not be that much of a problem at all. If it’s systematically missing with certain types of plans, certain types of providers about certain types of beneficiaries for certain types of services, it is important,” said Dr. Lawrence Casalino, MedPAC commission member.
Fellow MedPAC commission member Dr. Tamara Konetzka expressed surprise that the MDS doesn’t fully capture MA enrollee services. It’s been used for years to identify SNF and home health use among MA enrollees, and is used for care planning and quality measures as well as payments.
“[SNF providers] have a lot of incentives to fill out the MDS for every single patient. For SNFs it’s required of every resident in the facility, even if they’re not on Medicare or Medicaid. It should be pretty complete,” said Konetzka.
Moreover, the MedPAC report shows that encounter data was intended to capture the details of a MA beneficiary’s health and treatment, based on encounters with clinicians.
MedPAC commission staff Stuart Hammond and Andy Johnson found that the share of MA enrollees appearing in both data sources appear to have improved over time in the nursing home sector, from 66% in 2017 to 81% in 2021. Meaning, MA enrollees are increasingly being represented in both data from the MDS and MA encounters.
However, there are still 15% of MA SNF users that were found only in the MDS data, and 4% were found only in the MA encounter data. In other words, there are some MA enrollees that aren’t captured in at least one these data sources.
“While this may indicate missing encounter records, it is also possible that we included some MDS assessments of MA enrollees receiving services not covered under Medicare –, we would not expect there to be an encounter record for such services,” said Hammond, referring to dual eligible MA enrollees excluded from the report.
Latest in a string of MA scrutiny
The Centers for Medicare & Medicaid Services (CMS) in 2022 issued a proposed rule prohibiting MA plans from imposing coverage criteria that are more stringent than those applied in traditional Medicare coverage.
In January, CMS published its Interoperability and Prior Authorization final rule and proposed payment update for MA and Part D plans. The changes outlined in the federal agency’s final rule aim to streamline prior authorizations and promote easier electronic health record exchanges between providers and insurance plans, while also holding payers more accountable for denials.
Some Congressional leaders in November even called for an overhaul of the insurance option in the wake of admission denials and delays in medically necessary care.
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