Medicare Benefit plans and suppliers want to concentrate on the latest enhance in authorities enforcement of danger adjustment coding points. Previously few years, the Workplace of the Inspector Normal (OIG) and the Division of Justice (DOJ) have targeted on danger adjustment coding as an space prone to fraud which is able to doubtless proceed into 2022. See under for an outline of danger adjustment coding, latest enforcement examples, and 5 ideas for suppliers to assist guarantee correct coding.   

Threat Adjustment

Below the Medicare Benefit program, the Facilities for Medicare & Medicaid Companies (CMS) pays Medicare Benefit organizations (MAOs) a hard and fast per enrollee per thirty days (PEPM) quantity. For every enrollee, CMS adjusts the PEPM utilizing diagnoses and demographics to find out a danger rating which is meant to foretell how a lot such enrollee’s well being care will price for the plan yr.  With the intention to calculate the danger rating for an enrollee, CMS makes use of the diagnostic codes submitted by the enrollee’s well being care suppliers. In the end, CMS pays the MAO extra for enrollees with increased danger scores and fewer for enrollees with decrease danger scores.  

Since the next danger rating means a higher cost, there may be an incentive for sure suppliers (relying on how they’re paid by an MAO) to inflate danger scores which might result in overpayments from CMS and doubtlessly False Claims Act legal responsibility.  

Current Examples 

Under are a number of latest examples of the DOJ and OIG cracking down on improper danger adjustment coding:

• In January of 2022, the OIG launched a report inspecting funds to an MAO and its suppliers. This audit discovered quite a few upcoding points by the MAO’s suppliers that weren’t supported by the medical information and resulted in web overpayments to the MAO for over $500,000. 
• In October of 2021, Sutter Well being, in its function as a supplier, settled a False Claims Act case for $90 million for knowingly submitting inaccurate analysis codes.  Sutter allegedly had a number of aggressive packages that finally resulted within the submission of unsupported diagnoses.
• Additionally in October of 2021, the DOJ filed a grievance towards Kaiser Permanente for allegedly defrauding CMS of $1 billion by pressuring physicians to retrospectively add roughly half 1,000,000 analysis codes to sufferers’ medical information that have been non-existent or unrelated to the go to. This stress was accompanied by monetary incentives and rewards to the physicians.
• In September of 2021, the OIG launched a report that indicated that chart critiques and well being danger assessments have been being utilized by MAOs to inflate danger scores.
• In September of 2021, the DOJ filed a False Claims Act lawsuit towards Impartial Well being for forming an affiliate firm to conduct retrospective critiques of medical information to seize further analysis codes. This affiliate firm allegedly submitted varieties to the suppliers requesting signatures on further analysis codes that weren’t supported within the medical information. 
• In March of 2020, the DOJ filed a False Claims Act swimsuit towards Anthem for failure to conduct two-way medical chart critiques. Anthem allegedly used chart critiques to establish and submit further analysis codes however did not delete beforehand submitted codes that weren’t supported by the evaluate inflicting to overpayments from CMS. 

5 Suggestions for Suppliers

Under are high-level ideas for suppliers to assist guarantee correct risk-adjustment coding: 

1. Implement insurance policies and procedures and education schemes to make sure coding follows ICD-10 pointers and CMS steerage. 
2. Concentrate on potential points associated to coding from downside lists, packages that mine information for diagnoses and/or pre-populate analysis codes, and incentives or rewards to suppliers associated to submission of diagnoses and/or scheduling assessments.
3. If the supplier critiques charts for lacking diagnoses, make sure the evaluate additionally identifies analysis codes that ought to be deleted from the sufferers’ information. 
4. Implement strong auditing processes to observe coding practices.
5. Take corrective actions with respect to suppliers that report unsupported diagnoses. 

 is a companion in Thompson Coburn’s Well being Legislation Apply Group.   is an affiliate in Thompson Coburn’s Well being Legislation Apply Group.