Christi A. Grimm, the sixth inspector general of the U.S. Department of Health and Human Services, opened RISE National 2024 with a presentation on how to cultivate trust through a culture of compliance. Here are key takeaways from her speech at last week’s conference:
Grimm said that last year at RISE National she urged attendees to intensify their focus on program integrity, risk, and compliance. This year, she said during the presentation, ensuring that Medicare Advantage delivers cost-effective, high-quality care to seniors is one of her top priorities as Inspector General.
Expect continued scrutiny from OIG, CMS, lawmakers
Managed care is under the government and public microscope. Since this conference last year, scrutiny of managed care business practices and the enrollee experience has intensified.
RELATED: Warning from Inspector General: MA plans get ready for more OIG enforcement
Plans are drawing increased scrutiny from Congress and regulators for problematic risk adjustment and prior authorization practices, including the use of artificial intelligence. The Centers for Medicare & Medicaid Services is tightening regulations to compel improvements in plan operations. The number of fraud prosecutions involving managed care is up.
With more than half of Medicare beneficiaries enrolled in managed care plans and annual expenditures of more than $450 billion in scarce taxpayer funds—enough to fund more than 160 trips to the moon—the stakes are high. As long as significant gaps exist between the vision for managed care and current reality on the ground, plans and their business partners can expect continued scrutiny and mounting distrust.
Why trust and compliance matter
Trust is more than a branding exercise. It requires commitment, persistence, and leadership to do the right thing. Medicare Advantage cannot live up to its promise through government action alone. Plans must act, too. Persistent underperformance in meeting the goals and requirements of the Medicare Advantage program poses risk to business success and reputation. If underperformance veers into misconduct, the risks become even greater.
Where Medicare Advantage falls short
Managed care has tremendous curb appeal—but only if it can be trusted to deliver on its promised outcomes. Unfortunately, in some important ways, Medicare Advantage falls short of its vision… Stories about consumer dissatisfaction with Medicare Advantage abound…Although many Medicare Advantage enrollees are satisfied with their plans, chatter around the “seniors’ water cooler” is that Medicare Advantage plans deny medically necessary care, make patients jump through meaningless hoops, and put profits over patients. Some patients walk into their doctors’ waiting rooms and find warning signs about enrolling in Medicare Advantage.
Prospective enrollees study the marketing materials and the network directories, but their experience after enrollment often diverges from what those materials promised. The message some are conveying to their peers: “Steer clear of Medicare Advantage.” That is not the word of mouth you are looking for.
Gaps in care pose risk to patients and the program
All too often there are critical gaps between the attractive promise of managed care to deliver cost-effective, high-quality, coordinated care—and how it operates in practice. We see this in important areas like prior authorization and risk adjustment. These gaps, if not closed, pose real risk, not just to patients but also to managed care plans and the Medicare Advantage program. If Medicare Advantage plans and their partners cannot turn promises into realities, then it begs the question whether managed care was a mirage in the first place. And they risk eroding hard-to-earn trust of important stakeholders like consumers, providers, regulators, policymakers, and investors.
How to cultivate trust
Compliance is fundamentally about trust. It is an organization being committed to doing the right thing, to fixing what has gone wrong, and to meeting the needs of its stakeholders. Compliance with the rules of the road signals: “Being trustworthy matters to us.” I hope to persuade you to seize important opportunities for decisive actions that bolster compliance with Medicare rules, create business value, and reduce reputational risk. You can act to close gaps between the promise of managed care and the reality that it sometimes under-delivers on that promise.
How OIG can help
First, we are prioritizing managed care and executing on a new strategic plan for oversight with three clear goals: promoting access to care for managed care enrollees, providing comprehensive financial oversight, and promoting data accuracy and data-driven decisions. I encourage you to read our strategic plan; it is a roadmap to where we are going.
Second, we are continuing to collaborate with plans and our law enforcement partners to crack down on fraud that targets plans. Your partnership is crucial to identifying where fraud is happening.
RELATED: OIG’s new toolkit aims to cut improper payments in Medicare Advantage
Third, we are providing compliance tools, such as the toolkit for high-risk diagnosis codes.
Last year, we issued an updated General Compliance Program Guidance. It contains important information for compliance officers, as well as for company leaders and boards of directors. We anticipate issuing updated compliance guidance specific to managed care later this year.