Medicare Advantage plans remain under scrutiny as the Centers for Medicare and Medicaid Services (CMS) continues an aggressive strategy to identify and recoup overpayments tied to risk adjustment practices. Current CMS Administrator Dr. Mehmet Oz has doubled down on his push to expedite audits in an effort to increase recoveries. These audits are often triggered by allegations that the organization submitted the diagnoses without adequate clinical support, inflating patients’ illness severity and increasing plan payments.
What is the agency’s plan?
CMS is expanding and refining its audit approach, particularly through Risk Adjustment Data Validation (RADV) audits. These audits test whether diagnoses used to calculate risk scores are supported by medical record documentation and meet applicable coding rules. When CMS determines that a diagnosis is not properly supported, it may treat the related payment as an overpayment and seek repayment, sometimes across a broader population through extrapolation.
These RADV audits have received pushback, most recently when the Northern District of Texas tossed out the agency’s RADV final rule. In its decision, a federal judge removed the agency’s ability to extrapolate a sample audit to the entire organization. Regardless, CMS’s strategy continues to reflect a broader policy objective: to vigorously review documentation and root out bad coding practices that prioritize revenue over clinical accuracy.
Those within this field can use the following measures to help to better ensure they have what they need to withstand the scrutiny of an audit:
- Records. Medical record support for each submitted diagnosis, including clear provider documentation and appropriate signatures
- Correct coding. Coding accuracy and adherence to risk adjustment rules, including specificity and proper linkage to assessment and treatment
- Oversight. Oversight of vendors and downstream entities, such as risk adjustment consultants and chart review providers
With these measures in place, your business should have the information it needs to defend claims if it faces agency scrutiny.
What should my health care business do if we get an overpayment notice?
Those who find their organizations subject to an audit are wise to check the correspondence and note any listed deadlines. Gather and preserve records, including the notice, underlying claims data and relevant medical records before addressing the allegations.
The CMS is likely to continue its crackdown on abuse of the Medicare Advantage program. As such, those who operate in this area should continue to implement the measures noted above to protect their business in the event of an audit.
Attorney John Rivas is responsible for this communication.