As detailed in this article, Anthem is facing a lawsuit initiated by the Department of Justice (DOJ) for allegedly failing to remove erroneously submitted diagnoses from CMS’s database despite knowing that inconsistencies might be present. The health insurance carrier commissioned a retrospective chart review process from third-party vendor to evaluate coding accuracy. The vendor identified conditions that were overlooked and could be coded, and also revealed conditions reported in error, which warranted removal from the member’s diagnostic profile. Anthem did not process the removals. Consequently, the risk score was “inflated” by incorrectly reported conditions that accounted for increased revenue of around $100 million per year from 2014 to 2018. Even though Anthem refuses to acknowledge any wrongdoing, the plan is facing spending a long time in court rooms.
Physicians must recognize the importance of having a complete MRA program with a comprehensive auditing process that helps their practice to report diagnoses accurately; detect coding, documentation and submission inconsistencies; and notify the plan about any conditions that have been reported in error.