If you see a lot of Medicare Advantage patients in your practice, you could be in line for an audit. That’s the message from Kim Harvey Looney, a Nashville-based health care regulatory and compliance attorney.
“It’s important for providers to know that if they have a significant portion of patients on Medicare Advantage, they’re more likely to be audited,” Ms. Looney said during a webinar held by the American Health Lawyers Association.
Ms. Kim Looney
Continued growth of the Medicare Advantage (MA) program is one thing causing auditors – both federal and those who work for health insurers – to take a closer look, audit experts say. About 30% of all Medicare patients are enrolled in MA, according to a May report by the Kaiser Family Foundation. Since enactment of the Affordable Care Act, enrollment in the program has increased by 4.6 million, or by 41%. MA also accounts for a quarter of all Medicare spending, according to Kaiser Family Foundation data.
But the complex model under which MA operates can cause physicians to submit incorrect codes, Stephen M. Sullivan, a Los-Angeles health care attorney said.
The Centers for Medicare & Medicaid Services pays contracting health insurers per patient based on the patient’s risk adjustment scores. The scores are derived by the health status of the patient, so insurers get a higher stipend for sicker patients.
Risk adjustment scores themselves are based on diagnosis codes for previous visits to physicians; the plans then process and filter the information and send risk adjustment data to CMS.
“Risk adjustment in general, is complex, is very technical, and it is very data driven,” Mr. Sullivan said. “Because it is so data driven, there has been an acknowledgment within the industry, including from CMS, that there is a very high imprecision rate in the actual codes that are submitted.”
A July study published in the Medicare & Medicaid Research Review, a CMS publication, found that risk adjustment scores in the Medicare Advantage program were largely exaggerated by health plans and did not match enrollees’ morbidity. A June report by the Center for Public Integrity revealed similar findings.
Amid such criticism, the Office of Inspector General, in its 2014 Work Plan vowed to review the extent to which CMS is verifying the accuracy of MA encounter data and risk adjustment reporting.
For doctors, the spotlight on inaccurate risk scores means a sharper eye to coding and medical records from health plans and CMS auditors. Health plans, in particular, are searching both to ensure they were not underpaid by CMS because of undercoding, and that they aren’t audited due to overcoding.
Mr. George Breen
“There is more focus now (by CMS), both looking at the plan and looking at the provider as to whether or not there is accurate information being submitted,” said George B. Breen, a Washington-based health care attorney and chair of his firm’s National Health Care and Life Sciences Practice Steering Committee. “From the plan’s perspective, they have the obligation to make sure the money being spent is, in fact, consistent with the diagnosis being reported, and that they have looked to see whether or not the record by the physician supports the condition.”
Some of the coding confusion comes from the critical differences in information required by MA as compared with fee-for-service Medicare, said Julie Nielsen, director of a Tampa, Fla.–based health care research and dispute resolution company. Rather than noting only services rendered for a primary condition, physicians coding an MA claim must include all conditions that affected the patient encounter.
“It’s been a very big transition for physicians and providers having to become more attuned to capturing all of the members’ diagnosis codes that impacted the visit when the member was there, not just that the member was there for a lab draw and an office visit,” Ms. Nielsen said.
Alleged coding errors found by health plans or CMS can result in a health provider being kicked out of the program or affect their payments from health plans. Inaccurate information that results in an overpayment by CMS can also lead to a False Claims Act (FCA) violation, said Mr. Breen, who defends health providers in billing, fraud, and FCA investigations.
“Even though the claim may not have been directly submitted to Medicare, but to the Medicare Advantage plan, the government can argue the provider either submitted a false claim or caused a false claim to be submitted,” he said.
To prevent and defend MA audits, develop a strong compliance program that includes ongoing internal risk assessments, Ms. Looney said. In some cases, it may be helpful to hire a third-party company to review coding submissions and offer conclusions.