The Office of Inspector General (OIG) audits Medicare Advantage plans for, among other reasons, to assure they submit accurate and true information to the Centers for Medicare and Medicaid Services (CMS) and thereby, receive proper risk adjusted payments. The OIG’s auditing efforts are ongoing and much needed based on a September report that concluded 20 of the 162 MA companies drove a disproportionate share of $9.2B in payments from diagnoses that were reported on chart reviews and health risk assessments (HRAs) and on no other service records. The importance of that last snippet will become clear in a few paragraphs. In addition, the OIG informed that these companies’ higher payments could not be explained by the size of their enrollment as their earnings were 25% higher than would be generated by their share of enrollees.
Now, our company does thousands of chart reviews every single year and we never fail to identify new conditions our provider clients were not reporting. We bring them to the provider’s attention and urge him/her to assess the diagnosis at a future visit. However, chart reviews (and HRAs) have been used quite differently by MA plans, which has resulted in a huge change in the composition of CMS’s MA plan payments for 2022.
To be fair, CMS has allowed chart reviews and HRAs to be used as sources of diagnoses for risk adjustment. However, CMS has not required plans to link those chart reviews to previously accepted “records of service” provided to patients. Let’s back up for a minute: In basic terms, when a provider sees a patient, he or she makes an assessment of the patient’s medical conditions, risk adjusted or not, obviously; documents a visit note that summarizes the patient encounter and assessment of all diagnoses for that day; and submits to the plan the diagnosis codes and codes for the procedures carried out in order to have the claim paid or encounter processed. This procedure effectively logs the medical conditions in the health plan’s system for future transmission to CMS, who will include the conditions in the member’s profile and eventually reflect the weight of the conditions in the plan’s payment for that enrollee’s care.
However, since the risk adjustment payment system was established in 2003, plans have been able to submit conditions via the Risk Adjustment Processing Systems (RAPS) directly into CMS’s records. So let’s say the health plan conducted a chart review in a medical practice and found conditions in the chart that the provider had not included in a claim/encounter; the plan representative could enter those conditions for that past date of service – using a ‘default’ or dummy procedure code – and thereby log it for future payment. There is only one rub: the condition may not have been assessed by the clinician and may not even appear on the visit note for the date on which the plan’s rep submitted it – or any date, for that matter!
HRAs are summaries of a patient’s health conditions, presumably from a wellness standpoint to make a complete inventory of the patient’s health status and create a plan of care. Sounds noble enough and patient-focused, right? However, health plans and medical groups have long used HRAs, which can be really beneficial when part of the provision for medical care by the provider. However, many organizations’ HRAs are conducted in the patient’s home by non-medical practitioner vendors, and the HRAs’ data (e.g., medical conditions) is submitted to CMS. Our coders have witnessed countless HRA forms/templates – pre-populated with the patient’s historical conditions (active and past), medications, etc. – completed by a nurse with little in the way of an assessment, containing mostly templated counseling statements, such as, “Follow up with your PCP” and “Take your medication as directed,” and no additional coordination of care. Here again, the conditions from the HRA may not have appeared in other visit records by a medical practitioner, as the OIG highlighted in its report.
It’s not surprising that these activities resulted in the submission of inaccurate and unassessed medical conditions that rewarded plans and providers with millions of dollars in revenue, but we find the conclusions a bit staggering. Of the 20 MA companies flagged for these activities, one unnamed plan further stood out on its use of chart reviews and HRAs without encounter records. The report summarized that 40% of this plan’s risk adjusted payments resulted not from medical visits but from chart reviews and HRAs, that a third of the conditions resulted only from reviews and more than 50% from HRAs conducted in the home.
The CMS payment to health plans has been based on the information received from claims/encounters and directly through the RAPS. After a phase out of three years, 2022 is the first year when 100% of the plan’s payment will be based solely on information from claims/encounters. No more RAPS-submitted conditions will be factored into payments.
We often blog about irregularities in the risk adjustment space – to use today’s parlance – because they come close to our professional hearts. Since 2004, our company has worked with providers, medical groups and even health plans to achieve the most accurate risk adjusted payments possible for their enrollees. Our work is a blend of education, chart review, coaching, feedback and re-auditing. The chart reviews, specifically, have two components: mining the chart for conditions that have not been reported, and validating reported conditions and their documentation. It’s the last part everybody eschews. Except for the DOJ and OIG, that is.
Sadly, there is much gaming in risk adjustment, with medical groups taking great license in reporting conditions that don’t exist, aren’t properly supported, weren’t assessed by the clinician, are categorically contradicted by other chart documents, and/or frankly, strain credulity. When a medical condition is routinely reported by a practice at a rate that defies national and regional prevalence statistics, something is fishy. And those apples – let’s call them misguided and not necessarily bad – ruin it for everyone else.
You can read some of our blogs on prior audits of MA plans here: Anthem, Kaiser, Cigna, Humana.