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This blog is the first in a series of lessons, or reminders, gleaned from the Department of Justice’s (DOJ) lawsuit against health insurer Cigna.

The suit alleges that Cigna essentially committed fraud by reporting false information to CMS in a “widespread scheme to improperly increase revenue.”  At the heart of the lawsuit is Cigna’s use of the health risk assessment (HRA).  In this case, the HRAs were completed by a vendor employing nurses and non-physician practitioners, who visited the plan’s members in their homes, as part of what was purported to be a ‘data gathering’ exercise; these individuals are believed to have documented “suspected, possible, and otherwise unsupported, invalid health conditions” that were later submitted for payment.

For several years, CMS has been focusing on in-home HRAs, believing they may be solely to capture risk adjusted conditions and do not reflect any actual treatment of the conditions or health plan follow-up.  Many of the HRAs we’ve seen support this suspicion.   So, are HRAs a bad thing?

In short, no, HRAs aren’t bad, in theory; valid information can be captured and, if used properly, contribute to the member’s health and wellness, while also maintaining stable funding.  In Cigna’s case, the vendors received all the historical diagnoses reported for the member, and the plan allegedly expected the vendor to “capture” the conditions during the home visit.  We have seen a troubling version of this with some clients’ use of a pre-populated HRA form.  The form contains all the reported (MRA-only) diagnoses and the last time they were submitted by the PCP.

The first issue a regulator would question is, if the purpose of the HRA is to assess the patient’s health status, why are only the risk adjusted conditions listed?  Or if all conditions are included, why are the risk adjusted ones highlighted, italicized, or denoted with an identifier, such as an asterisk?  These practices support the suspicion that HRAs are an MRA-only exercise.  From a practical standpoint, we understand the need to conduct these assessments, but they should truly give equal time and attention to all the patient’s medical conditions and not just those that carry additional payment.

The second challenge we see is the historical listing of reported conditions.  One should ask, what is the source of these conditions?  In all likelihood, they were culled from previous encounters and paid claims submitted by all types of providers.  However, our 17 years doing MRA work have shown that not all submitted diagnoses are valid.  Inpatient documents can contain suspected or resolved conditions, which if not properly reviewed by the PCP, can be erroneously reported in primary care encounters as confirmed.  Similarly, we have seen specialist consultation notes which list differential diagnoses that may have been reported on a claim or encounter, and to the untrained or unskilled, these can be mistakenly accepted as valid. Consequently, the historical listing on the HRA will perpetuate the reporting of false conditions.

The Cigna documents allege that the HRA conditions were not assessed by the in-home provider, but merely accepted at face value, without objective corroboration, and subsequently reported.  A “man-on-the-street”-type interview of clinicians would yield widely varying beliefs about the proper elements of an assessment.  For some, listing evidence of a medical condition and a cryptic, “Stable, continue current treatment” is believed to be sufficient.  However, the DOJ lawsuit reminds us that reported conditions are those that “require or affect patient care, treatment or management;” the natural extension of that idea centers on its documentation.

Risk adjusted documentation must include two important elements:  evidence and assessment.  And both must be on the progress note.  Imagine, if you will, packaging the clinician’s note with a big red bow for CMS!  The gift should contain everything needed to – er – enjoy the contents!  Moving away from the goofy analogy and on a more serious note: the assessment must hang MEAT on the bone of the diagnosis listing and properly convey how each condition is being Managed, Evaluated, Assessed and Treated. (I couldn’t resist one more!)  By extension, MEAT includes the plan, or next steps in the treatment regimen.  All of these satisfy the need to show, as required in the CMS manual, how the conditions “require or affect patient care, treatment or management.”

Join us next time as we continue applying the lessons learned from the Cigna/DOJ lawsuit.

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