When the Centers for Medicare and Medicaid Services (CMS) risk adjustment data validation (RADV) audit identified coding errors for one Humana contract representing members in South Florida, the Office of Inspector General (OIG) conducted its own audit. We should recall that the OIG’s role is as an independent entity whose mission is to promote integrity, efficiency, and accountability within the Department of Justice so as to combat fraud, waste and abuse.
The OIG’s audit focused on ICD-9-CM codes (the coding version in effect in 2014) submitted for 200 randomly selected enrollees and which mapped to 1,525 hierarchical condition categories (HCCs). HCCs are the basis for the majority of the payments made from CMS to MA plans on behalf of enrollees each month. The bottom line of the OIG review is that payments should have been based on 1,359 HCCs instead, representing an overpayment to Humana of $197 million in 2015.
Some big take-aways from the lengthy OIG summary report are:
- Underpayments and overpayments are two sides of the same coin. Although we might think it’s to the federal government’s advantage to have underpayments, both are errors and both are costly. Underpayments affect the MA plan and the providers of care because payments do not reflect the true anticipated cost of providing care to a member.
- OIG concluded that about 82% of the HCCs that factored into Humana’s payments represented medical conditions that were not supported in the medical record. This point is a daily fact for those of us in the business of auditing risk adjusted payments. One way to mitigate the potential for unsupported conditions is to have providers list the evidence of each MRA diagnosis in a static portion of the progress note. This is not a magic wand, of course, but the process of documenting actual evidence forces the provider to review it more critically and, in our estimation, confirm that it is accurate.
- Another important point is the assertion in the OIG report that although a diagnosis may be listed in a progress note or medical record, there must be documentation that indicates the condition was “monitored, evaluated or treated.” A recent CCG blog advises providers to mentally shift their focus away from believing risk adjusted payment is based on the member’s illnesses and consider it dependent on the PCP’s documented management of those illnesses. What can coding staff do in this regard? Scrutinize medical documentation to assure PCPs are actually assessing the condition on each date of service that it’s reported and hold the provider’s documentation to the tried-and-true M-E-A-T standard.
- For about seven percent of the HCCs, OIG concluded that additional diagnoses should have been – and were not – submitted to CMS, and could have factored into MA plan payments. Some of our clients inquire about the need to report more than one diagnosis code for each HCC, and our response is always the same: report everything you are M-E-A-T-ing for your patient, regardless of the HCCs. This means that if a member has several conditions that map to the same HCC, it behooves the clinician to report them all because: 1) the patient actually has the conditions and the progress note is a legal document, 2) one or more conditions mapped to the same HCC may be disallowed due to faulty support or a M-E-A-T-less record, and another condition will carry the payment.
We would be remiss not to remind you that all coders are not equally skilled at identifying medical condition support or objectively assessing their work for errors. The ‘independent’ aspect of the OIG adds support to the idea of a third-party coding audit; independent entities are not influenced by the hierarchy of your organization and their only agenda is to validate the codes submitted for payment.