“You are leaving money on the table” is a common phrase Medicare Advantage providers hear from some auditors and even health plans regarding members’ risk scores. And that might be true. Some risk adjusted diagnoses may have fallen through the cracks even though the patient is being actively treated for all those unreported conditions. In this case, the patient’s risk score wouldn’t reflect an accurate picture of the financial impact of his or her health status on the medical practice.
After conducting countless audits through the years, CCG has found that even though some practices may under-report certain diagnoses, other conditions have been submitted in error due to lack of confirmation, insufficient documentation, and improper coding. A recent review involved 3,265 codes from two HCCs (18 Diabetes with chronic complications and 108 Vascular diseases), which were reported from 2016 to 2019; audit results revealed that only 19.7 % of the codes could be validated. Therefore, a little more than 80% of the codes were retroactively removed and with them, the medical practice’s funding.
Some providers fear that removing erroneous or unsupported codes will subject them to extreme scrutiny. The truth is that not removing mistakenly reported diagnoses is not only financially, but legally, dangerous. Providers and Medicare Advantage plans have a legal responsibility to comply with CMS’s guidelines for reporting diagnoses. A recent example of the legal implications of a “one-sided” auditing process that only detects new diagnoses but doesn’t rectify erroneously reported conditions is the lawsuit against health insurance provider Anthem initiated by the Department of Justice (DOJ). To read about the DOJ’s lawsuit against Anthem, visit our previous blog here.
Removals are important because:
- Providers have an ethical responsibility to maintain an accurate patient medical record.
- The patient’s risk score must reflect only confirmed diagnoses for accurate reimbursement.
- Failing to remove incorrectly reported diagnoses after having detected inconsistencies can be considered fraud.
- Sending a removal report, when necessary, shows the provider’s intention to maintain an accurate risk score.
- The practice compliance plan requires accurate coding.
The best ways to minimize removals are to have a strong MRA program and continuously educate providers on proper documentation practices. For more information on how to properly chart conditions and avoid having risk adjusted diagnoses removed due to insufficient documentation, you can read our reminders here.
Read Full Post Comments Off on “Removals” is not a bad word!