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(2022) Federal Departments of Health and Human Services and Department of Justice: Health Care Fraud and Abuse
search this document for "medical loss ratio"

(2023) The Avaricious Ascent of UnitedHealth Group

Whistle Blower Lawfirm website:  Fraud in Medical Loss Ratio Reporting

(2023) Myers and Stouffer 2023 CMS Rule Review (MLR Expense Allocation)

(2023) pdf regarding CMS changes to MLR calculation

(2022) Questionable Quality Improvement Expenses Drive Proposed Changes to Medical Loss Ratio Reporting

(2022) Managed Care Under Scrutiny (MLR discussed)

(2022) Georgetown University : Medicaid Managed Care: What Can the Annual MLR Report Tell Us?

"the data element for spending on activities that improve health care quality is vulnerable to manipulation. CMS has documented instances in which insurers that offer products on the Marketplaces have loaded costs into this expenditure category that do not belong there, such as costs related to marketing, lobbying, entertainment, and travel. Presumably, they do so in order to increase their MLRs and avoid paying rebates to consumers. This is directly relevant to Medicaid because Medicaid uses, in part, the same regulatory definition of “activities that improve health care quality” that applies in the Marketplace. In states that impose minimum MLR requirements and enforce them by requiring remittances, MCOs have an incentive to inflate their spending on these activities when necessary to meet their MLR targets and avoid paying remittances.

False Claims Act dangers lurk

"The MLR is expressed as health care spending divided by revenue. Health care spending or the numerator of the MLR is the sum of health plan spending on incurred claims and activities that improve health care quality, as provided in the private market rules at 45 CFR 158.150.6.  Revenue or the denominator of the MLR is adjusted premium revenue (premium revenue from the state minus federal, state, and local taxes and fees).

To be counted in the numerator, activities that improve health care quality must meet the following requirements:

      • improve health care quality;
      • increase the likelihood of desired health outcomes in ways that can be objectively measured and of producing verifiable results and achievements;
      • be directed toward individual enrollees or incurred toward the benefit of specific segments of enrollees;
      • be grounded in evidence-based medicine, widely accepted best clinical practice, or criteria by recognized groups; and,
      • primarily fall into one of five categories: improve health outcomes, prevent hospital readmissions, improve patient safety, promote health and wellness, or enhance the use of health care data.
Administrative expenses (e.g., provider contracting, member services, utilization review, claims processing), reserves, and profit cannot be included in the numerator.
The denominator includes adjusted premium revenue, which is the health plan’s premium revenue minus the plan’s federal, state, and local taxes and licensing and regulatory fees. Incentive payments are not counted as premium revenue for purposes of the MLR; only capitation payments made for required services under the contract are included in the denominator.

Federal Office of Inspector General (2024) Managed Care Oversight Strategy and Fraud Reports

(2021) Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate

"half of States did not provide complete or accurate information about the amounts that managed care plans pay to providers for services-the amount paid"

(2022) Complete Report link inside: CMS Has Opportunities To Strengthen States' Oversight of Medicaid Managed Care Plans' Reporting of Medical Loss Ratios

"49 percent of the 495 MLR reports reviewed were incomplete. These incomplete MLR reports were missing at least one of seven numeric data elements that are essential to the MLR calculation. This missing data occurred across four of the seven MLR report data elements-non claims costs; taxes and fees; member months; and quality improvement activity expenses.

The data element for non-claims costs, generally defined as plans' expenses for administrative services, accounted for the majority of incomplete MLR reports. Missing data on non claims costs may reduce transparency on managed care spending and limit States' ability to ensure that plans are appropriately spending Medicaid dollars on the health of enrollees rather than excessive administrative expenses. Even when the data element for non-claims costs appeared in MLR reports, plans did not report this data in a consistent manner.

Whistleblower Protections in Colorado (2022) BROWNSTEIN CLIENT ALERT, AUGUST 4, 2022

Colorado False Claims Act (2022)

Colorado Medicaid Behavioral Health Provider Network

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