CMS announces massive audits of Medicare Advantage plans; time for compliance is now

By Jason Jobes, SVP, Solutions

HUGE CMS AUDIT ALERT: CMS just dropped major news that they are exponentially increasing Medicare Advantage and risk adjustment audits. WOW!

Our Norwood team has become an industry leader in understanding the nuances of Medicare Advantage audits, risk score accuracy, and education. Are you ready? Is your outpatient CDI program ready? How about compliance?

Let me start by saying I am a massive proponent of ensuring organizations get every dollar that they deserve in risk adjustment. It is an imperative in risk-based contracts. You should have a complete and holistic approach to patient complexity. One of those facets is making sure you have compliance checkpoints built in.

CMS just announced that “beginning immediately, CMS will audit all eligible MA contracts for each payment year in all newly initiated audits and invest additional resources to expedite the completion of audits for payment years 2018 through 2024.” Data from prior audits and government findings estimate the potential over capture of conditions to be around $17-43B, as in billion, dollars annually. That is a tremendous amount. Interestingly there hasn’t been much focus on MSSP or ACO performance but I suspect that will be coming soon.

Here are a few key points:

1. Enhanced technology: It sounds like the government will start to use NLP and predictive software to identify trends.
2. Massively increasing coders: Coders will surge from 40 to 2,000. This is a 50X increase. Wow.
3. Increased audit volume: CMS plans to increase audits from 60 per year to ALL eligible MA plans. Wow X2.
4. Extrapolating impact: CMS is increasing the sample size to make the extrapolation impact more statistically valid.

This will have a significant ripple effect across the industry. Medicare Advantage plans have been under scrutiny and couple this with the V28 impacts and the profit model is under tremendous pressure.

So what can you do?

1. Know how you perform: First, assess your current state of documentation and billing practices.
2. Leverage technology: Use your EHR to its full potential. If it makes sense, invest in additional technology like natural language processing to help read record accuracy.
3. Evaluate current practices: Evaluate your compliance, education, and data analytics programs to understand where you need to improve.
4. Engage providers: This includes building outpatient CDI programs for pre-visit, post-visit / pre-bill, and retrospective programs to help drive accurate documentation. Bring specific performance back to providers to ensure they are empowered to document effectively.

With this news I am delivering a webinar on Tuesday, June 3, from 1-2 p.m. EST (register here, its free) highlighting all of the OIG reviews since 2022. We will dive into the results and what you as an organization should be doing.

If you have questions, please reach out to me directly. We are happy to be your partner. You can reach me at jason@norwood.com.