• On July 16, 2015, GAO released a report entitled “Patient Protection and Affordable Care Act: Observations on 18 Undercover Tests of Enrollment Controls for Health-Care Coverage and Consumer Subsidies Provided under the Act”. To assess the enrollment controls of the federal Health Insurance Marketplace (Marketplace), GAO performed 18 undercover tests, 12 of which focused on phone or online applications. During these tests, the Marketplace approved subsidized coverage under the Affordable Care Act (ACA) for 11 of the 12 fictitious GAO applicants for 2014. The GAO applicants obtained a total of about $30,000 in annual advance premium tax credits, plus eligibility for lower costs due at time of service. For 7 of the 11 successful fictitious applicants, GAO intentionally did not submit all required verification documentation to the Marketplace, but the Marketplace did not cancel subsidized coverage for these applicants. Other observations included:
    • The Marketplace did not accurately record all inconsistencies.
    • Under PPACA, filing a federal income-tax return is a key control element, designed to ensure that premium subsidies granted at time of application are appropriate based on reported applicant earnings during the coverage year. GAO, however, found errors in information reported by the Marketplace for tax filing purposes for 3 of its 11 fictitious enrollees, such as incorrect coverage periods and subsidy amounts.
    • The Marketplace automatically reenrolled coverage for all 11 fictitious enrollees for 2015.  For an additional six applicants, GAO sought to test the extent to which, if any, in-person assisters would encourage applicants to misstate income in order to qualify for income-based subsidies during coverage year 2014. However, GAO was unable to obtain in-person assistance in 5 of the 6 undercover attempts.
  • On July 17, 2015, the Medicare Payment Advisory Commission (MedPAC) published the June 2015 edition of MedPAC’s Data Book, entitled “Health Care Spending and the Medicare Program”. The MedPAC Data Book provides information on national health care and Medicare spending as well as Medicare beneficiary demographics, dual-eligible beneficiaries, quality of care in the Medicare program, and Medicare beneficiary and other payer liability. It also examines provider settings—such as hospitals and post-acute care—and presents data on Medicare spending, beneficiaries’ access to care in the setting (measured by the number of beneficiaries using the service, number of providers, volume of services, length of stay, or through direct surveys), and the sector’s Medicare profit margins, if applicable. In addition, it covers the Medicare Advantage program and prescription drug coverage for Medicare beneficiaries, including Part D.
  • On July 15, 20015, the HHS Office of Inspector General (OIG) released a report entitled “The Fraud Prevention System Increased Recovery and Prevention of Improper Medicare Payments, But Updated Procedures Would Improve Reported Savings”. OIG found that in the third implementation year of the FPS in calendar year (CY) 2014, the Department complied with the requirements of the Small Jobs Act of 2010 (the Act) for reporting actual and projected savings in the Medicare Fee-for-Service program and the return on investment from the use of predictive analytics technologies. In addition, in CY 2014, the Department’s use of the FPS generated a positive return on investment, and the Department continues to provide oversight, management, and control of selecting and developing new models, enhancing existing models, and implementing system changes to improve the FPS. To help identify and better report FPS savings, OIG recommended that the Department provide its contractors with improved written instructions on how to attribute the FPS savings accurately and better document the contribution of the FPS leads toward achieving administrative actions.
  • On July 15, 2015, Avalere released a new analysis which finds that the average provider networks for plans offered on the health insurance exchanges created by the ACA include 34 percent fewer providers than the average commercial plan offered outside the exchange. The new data quantifies anecdotal reports that exchange networks contain fewer providers than traditional commercial plans. “Plans continue to test new benefit designs in the exchange market,” said Dan Mendelson, CEO at Avalere. “Given the new requirements put in place by the ACA, network design is one way plans can drive value-based care and keep premiums low.”