Code Red: CMS announces massive audit expansion of Medicare Advantage, raising risk adjustment coding questions

By Brian Murphy

For a while I felt like this was coming to a head.

As far back as 2016-2017 I was monitoring reports of Medicare Advantage (MA) plans under investigation for alleged fraud related to HCC upcoding. I wondered when we’d see massive, coordinated action.

That day is here.

On May 21 CMS announced a “significant expansion” of its auditing efforts for MA plans. See link below for the announcement in full, as well as a slide deck on the news presented by my colleague Jason Jobes. Here are some of my thoughts.

One of the biggest problems are semi-loose rules around risk adjustment coding. Because of the importance of chronic conditions in the capitated MA payment model, plans are incentivized to document and code them year over year in a face-to-face encounter. The way this is often done is through the use of the acronym MEAT, i.e., was the diagnosis monitored, evaluated, assessed, or treated.

But MEAT has never been codified in any official guidelines. It’s just a handy acronym, providing a framework to help coders and providers ensure that a diagnosis is properly supported in clinical documentation.

So is “evaluation” of something like major depressive disorder enough to pick up that diagnosis, in something like a home health assessment? We do have the Risk Adjustment Data Validation (RADV) rule as one guide, but there is plenty of gray in what constitutes “sufficient” documentation. MEAT is not listed in the RADV rule, but the Medicare Managed Care Manual is. That states any diagnosis submitted for reimbursement must be clinically supported in the documentation.

MA companies argue they want to have every condition coded and captured for purposes of adequate care funding and keeping patients out of the hospital. But are these conditions actually being treated? Does improved capture lead to any noticeable difference besides reimbursement?

In short, are MA plans keeping patients healthier? Or are for-profit plans with a fiduciary responsibility to their shareholders warped by upcoding incentives?

We’ve got questions, and trust seems sorely lacking. For CMS, it’s time to verify.

A couple final takeaways:

  • CMS’ call to hire 2000 coders, alone, is interesting, speaking on behalf of a solutions company that provides on-demand talent. Finding good coders who also have the ability to audit will not be easy. Where will they get them?
  • The call for greater audit technology is also interesting. While I don’t have a crystal ball I feel like CMS has been lagging insurance and hospitals here. The call to enhance its tech probably tells us all that we need to know. CMS has been behind and means to ramp up.
  • Extrapolation will be a tool in their arsenal.

Interesting times. If you enjoy this sort of thing, get ready. We’ll be covering this in detail as it unfolds.

References

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