Monday, March 7, 2022

The OIG and Medicare Advantage Risk Adjustment Audits: What You Need to Know

by Ellen Johnston, RHIA, CRC, COC-A

The Centers for Medicare and Medicaid Services (CMS) makes payments to Medicare Advantage plans to assist with covering their enrollees’ costs of care.  These costs are predicted using the CMS-HCC risk adjustment model, where diagnosis codes are grouped together into categories with similar resource needs and clinical intensity called hierarchical condition categories, or HCC’s. These diagnoses that map to an HCC carry a certain weight that correlates to the level of resources that will be needed to care for the enrollee with the diagnosis.  Diagnoses that are coded by healthcare providers during a certain calendar year act as a predictor for the projected costs for the enrollee for the following calendar year. 

If proper coding guidelines are not followed, it is possible for diagnoses to be submitted for enrollees that 1) may not exist or 2) represent a higher burden of illness than what the enrollee has, resulting in overpayments from CMS to the Medicare Advantage plan. 

The OIG has had a renewed focus on auditing health plans’ risk adjustable diagnoses, and just this year in 2022 there have been three published audits on health plans.  OIG has outlined seven focus areas for their audits.

  1. Acute Stroke
  2. Acute Heart Attack 
  3. Acute Stroke and Acute Heart Attack Combination 
  4. Embolism 
  5. Vascular Claudication 
  6. Major Depressive Disorder 
  7. Potentially Mis-keyed Diagnosis codes

These seven areas of focus were determined based on the high risk of being inappropriately coded. 

An example of this would be an acute stroke.  Typically, an acute stroke diagnosis code should not be utilized in the outpatient setting.  If an enrollee has a diagnosis of acute stroke come through on a physician claim during the year but has no evidence of this diagnosis during an inpatient stay, this would be considered as ‘coded in error’ on an OIG audit since a personal history code for stroke should have been used. This error would have caused the health plan to be overpaid for that enrollee—the acute stroke diagnoses map to an HCC, where the personal history code does not.

Below is an outline of three audits that have been published in 2022.  There are major estimated financial implications that can occur for health plans if these risk adjustable conditions are not accurately coded and supported with documentation in the medical record.  The total estimated amounts were based on the sample of cases that were reviewed in each audit.  You can find the full reports to each audit and how the health plans responded to the results at www.oig.hhs.gov. 


Here are a few tips to ensure that wherever you work, you are helping with the compliance of risk adjustment coding:

  1. Make sure you are up to date with the most recent version of the ICD-10-CM coding guidelines.  This is the first line of defense against inaccurate coding. 
  2. Get access to AHA’s coding clinic if you don’t already have it.  OHIMA also offers webinars on AHA coding clinic updates each quarter.  This can be a more affordable option if you are paying out of pocket for these updates. 
  3. Make sure you are familiar with which diagnoses map to those CMS-HCC’s and are aware of how they may appear in your daily workflow. The HCC diagnosis mappings can be found on CMS’s website. 
  4. Educate the providers that you work with on updated coding guidelines and the CMS-HCC categories. Education is key and getting provider buy in can be difficult but well worth the effort. 
  5. Stay up to date on any yearly changes that are made to CMS-HCC model through CMS releases, and keep updated on audits that are occurring within OIG.  


References:

Frontz, Amy J. “Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Healthfirst Health Plan, Inc. (Contract H3359) Submitted to CMS.” Department of Health and Human Services - Oig.hhs.gov, Department of Health and Human Services Office of Inspector General, 7 Jan. 2022, https://oig.hhs.gov/oas/reports/region2/21801029.pdf.

Grimm, Christi A. “Medicare Advantage Compliance Audit of Diagnosis Codes That SCAN Health Plan (Contract H5425) Submitted to CMS.” Department of Health and Human Services - Oig.hhs.gov, Department of Health and Human Services Office of Inspector General, 3 Feb. 2022, https://oig.hhs.gov/oas/reports/region7/71701169.pdf.

Frontz, Amy J. “Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Tufts Health Plan (Contract H2256) Submitted to CMS.” Department of Health and Human Services - Oig.hhs.gov, Department of Health and Human Services Office of Inspector General, 14 Feb. 2022, https://oig.hhs.gov/oas/reports/region1/11900500.pdf.



The Privacy and Security Snapshot is a new publication by OHIMA that will be published quarterly throughout 2021-2022.  The goal is to keep OHIMA members informed of current events in the privacy and security arena.

 Do you have suggestions on topics to include in the snapshot? Or are you a privacy/security guru who would be interested in contributing? Email ohima@ohima.org to get in contact.



About the Author 


Ellen Johnston, RHIA, CRC, COC-A is the current Director of Privacy & Security on the OHIMA FY 2021-22 Board of Directors. Ellen is the Program Manager of Risk and Coding Accuracy at Mount Carmel Health Partners.
 



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