Medicare Benefit plans and suppliers want to concentrate on the current enhance in authorities enforcement of threat adjustment coding points. Previously few years, the Workplace of the Inspector Common (OIG) and the Division of Justice (DOJ) have targeted on threat adjustment coding as an space prone to fraud which can seemingly proceed into 2022. See beneath for an summary of threat adjustment coding, current enforcement examples, and 5 ideas for suppliers to assist guarantee correct coding.   

Danger Adjustment

Beneath the Medicare Benefit program, the Facilities for Medicare & Medicaid Providers (CMS) pays Medicare Benefit organizations (MAOs) a hard and fast per enrollee per 30 days (PEPM) quantity. For every enrollee, CMS adjusts the PEPM utilizing diagnoses and demographics to find out a threat rating which is meant to foretell how a lot such enrollee’s well being care will price for the plan yr.  As a way to calculate the danger rating for an enrollee, CMS makes use of the diagnostic codes submitted by the enrollee’s well being care suppliers. Finally, CMS pays the MAO extra for enrollees with larger threat scores and fewer for enrollees with decrease threat scores.  

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

Latest Examples 

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

• In January of 2022, the OIG launched a report analyzing 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 data and resulted in internet 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 applications that in the end resulted within the submission of unsupported diagnoses.
• Additionally in October of 2021, the DOJ filed a grievance in opposition to Kaiser Permanente for allegedly defrauding CMS of $1 billion by pressuring physicians to retrospectively add roughly half one million analysis codes to sufferers’ medical data that had 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 threat assessments had been being utilized by MAOs to inflate threat scores.
• In September of 2021, the DOJ filed a False Claims Act lawsuit in opposition to Unbiased Well being for forming an affiliate firm to conduct retrospective critiques of medical data to seize extra analysis codes. This affiliate firm allegedly submitted varieties to the suppliers requesting signatures on extra analysis codes that weren’t supported within the medical data. 
• In March of 2020, the DOJ filed a False Claims Act swimsuit in opposition to Anthem for failure to conduct two-way medical chart critiques. Anthem allegedly used chart critiques to determine and submit extra analysis codes however didn’t 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 tips and CMS steerage. 
2. Pay attention to potential points associated to coding from downside lists, applications 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’ data. 
4. Implement strong auditing processes to observe coding practices.
5. Take corrective actions with respect to suppliers that report unsupported diagnoses. 

Nicole Jobe is a associate in Thompson Coburn’s Well being Regulation Observe Group. Catherine Feorene  is an affiliate in Thompson Coburn’s Well being Regulation Observe Group.