Medicare Managed Care
Payment Validation
Located under the Medicare Managed Care Program Integrity Contract (MMC-PIC) umbrella, the Medicare Managed Care Payment Validation (MMCPV) task order established IntegriGuard as the national processor for all retroactive changes requested by Medicare Advantage Organizations (MAO).
This task order, awarded by the Centers for Medicare & Medicaid Services (CMS) to IntegriGuard in 2002, focuses on processing retroactive requests for changes to enrollment, demographic data, and special health status categories.
MAs, MA-PDs, and PDPs:
Click here for retroactive SOPs and submission process
What We Do
For the MMCPV task order, IntegriGuard supports CMS' program integrity efforts as follows:
- Completes all retroactive payment adjustments and enrollment adjustment requests submitted by MAOs
- Completes final reconciliation of payment for non-renewals of MAO contracts
- Makes reconsideration determinations with plans that are appealing decisions regarding payments
- Completes monthly analysis of plan discrepancies and reports out on these activities
Background of MMCPV Program
Medicare Managed Care programs operate under Section 1876, Section 1833, and Sections 1851 through 1859 of the Social Security Act. These statutory provisions authorize CMS to make payments to eligible managed care organizations on both a cost and a risk basis. Currently, 5.5 million Medicare beneficiaries enrolled in 196 organizations are paid a total, on average, of $3 billion on a monthly basis.
Cost-based organizations are paid based upon an annual budget submission by the contracting organization. Risk-based payments to MAOs and some demonstration projects consist of a monthly capitation payment based upon demographic characteristics of each Medicare enrollee.
Demographic characteristics include age, sex, county of residence, Medicaid status, inpatient status, employment status, End-Stage Renal Disease (ESRD) status, and hospice election. Information regarding the demographic characteristics of each beneficiary comes from several sources, including Medicare beneficiaries, CMS databases, Social Security Administration (SSA) data, and contracting managed care organizations.
Monthly capitation payments are calculated differently for cost versus risk-based organizations. However, all requests for enrollment are received from the MAOs and submitted to the CMS managed care enrollment and payment system.
The CMS master beneficiary database record is checked for Medicare entitlement, and the individual's residence and health status information (demographics) is collected from the source databases. This information, along with the type of managed care organization, determines the capitation amount the MAO will be paid for the beneficiary for that month.
Several special factors impact the individual beneficiary payment, and therefore, the aggregate payment to the organization. Those special factors include Medicaid status; institutional status; and ESRD status. Many of these parameters are self-reported by the MAO (e.g., institutional status) or require complex system interaction. In some instances (e.g., ESRD status) the payment level is significantly impacted.
In addition to the special factors, the geographic component of the payment, the "state and county code," is especially susceptible to fraud and error.