Compliance on Steroids

A recent review of filings against Medicare Advantage health plans by the federal government makes it clear that Medicare Risk Advantage (MRA) compliance is being poorly managed and supervised by the health plans. And that the government considers it fair game to recoup its prior payments by auditing the documentation that the plans must validate their filing of the Hierarchical Condition Category (HCC) codes.

A health plan in California is charged with a whistle-blower lawsuit and it seems apparent that the basic processes of documentation were not followed. Providers were asked to addend HCC codes retroactively and these codes were billed to the Center for Medicare and Medicaid Services (CMS). The codes that had been billed in error were not deleted by the health plan once the error in billing was discovered.

Several other national health plans are on the dock for the billing erroneously. A federal audit estimates that a prominent health plan in Florida might have been overpaid nearly 200 million dollars which needs to be refunded. We believe that this trend will only continue as the Federal government continues to focus on refurbishing its coffers to reduce the fiscal deficit that has expanded significantly in the past year and a half due to COVID-19 epidemic.

It is obvious that most health plans and management service organizations (MSOs) not only have poor processes in auditing MRA compliance, but they also significantly lack in expertise regarding the same. Most compliance officers are not trained in HCC codes and the clinical aspects of medicine to be of any help in creating a program that protects the organization from MRA audits.

An extremely strong program of MRA compliance is needed among primary care practices. MSOs and health plans to ensure that they become audit-proof as far as humanly possible and get paid appropriately and with due checks and balances. Most organizations dealing with Medicare Risk Advantage patients do not have proper education platforms or training for the doctors or providers. Data management is poor and gap analysis limited. Auditing is done by poorly trained auditors and billing processes and documentation focuses only on enhancing MRA scores without a review of codes that must be deleted.

A robust MRA compliance will need to consist of all the following:

1) A strong and up to date education program for providers that does not lead them and give them the tools to document appropriately without leading them to various diagnoses.

2) Clear policies and procedures that are circulated to all who are part of the revenue cycle.

3) A team of educators, clinical documentation instructors, billers and auditors who work together and evolve a system that adheres to the regulations and coding guidelines.

4) A process of data management that can review and validate HCC codes and ensure they reach CMS so that correct payment and premium is issued.

5) Constant review of each code and shift in guidelines so that the organization is acting preemptively and proactively.

The silver lining to these caveats is that in our experience as the organization audits and deletes codes that have been billed erroneously, it also discovers that there are many conditions that have not been documented and billed appropriately. But for that to happen a very focused approach to MRA compliance is needed from the top leadership and deployment of the best industry standards and systems is needed to protect themselves from possible refunds and penalties in the future. The risk is real now and gathering more strongly than ever.

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