Latest OIG report: $59M reasons to ensure accurate HCC capture

Latest OIG report: $59M reasons to ensure accurate HCC capture

By Jason Jobes

Want $59M worth of reasons to ensure accurate HCC capture? Read the latest OIG audit report of Medicare Advantage, this time of MMM Healthcare.

While the penalty was only $165k, had extrapolation started in 2017 (the time period of this review) it could have been massive.

For the first time in a while the OIG released a review of randomly selected patients. While the OIG has been focusing efforts on the targeted review, with the onset of extrapolating impact beginning for 2018 dates of service, I believe these are going to become the new trend.

A few notes on the review:

• 200 patients reviewed in the audit
• Of those 200 patients, 688 conditions were submitted for risk adjustment
• The OIG validated 580 HCCs of the original 688 submitted. This means 15.7% were not supported in the documentation.
• The OIG found 22 net new HCCs not previously submitted
• The total impact for the net 86 conditions removed (688 submitted – 580 validated + 22 found) was $165,312
• The extrapolated impact is $59M

This should be a huge eye opener for organizations focused on risk adjustment. By all means, organizations must do everything they can to get credit for what they deserve; however, it is vital to ensure appropriate checks and balances in place.

The same also holds true for under-coding and missed diagnoses.

For example, the audit also discovered that MMM did not submit a diagnosis code for “Hypertensive Heart Disease With Heart Failure,” which was supported by the medical records. This oversight led to an underpayment that could have been avoided with better documentation practices (nice to see that the OIG is not all about fines and penalties, but overall accuracy—at least in this report).

It should be noted that the MA plan in question refutes some of the findings and the methodology. I expect the intensity of these disagreements will be expanding in the coming months as the extrapolated impacts from reviews for 2018 and beyond begin.

For CDI professionals, this latest audit serves as a reminder that your work directly impacts not only reimbursement but also the integrity of patient data. It’s also a reminder that accurate coding isn’t just about compliance; it’s about ensuring that healthcare providers are compensated fairly for the care they deliver, and that patients’ health statuses are accurately represented. 

How is your organization strengthening its CDI processes to support accurate risk adjustment and compliance? Let’s share strategies that are working well. 

As always, I would love to hear from you. You can hit me up on LinkedIn where I’m always talking Medicare Advantage, risk adjustment, coding and compliance, and more. Or just send me an email at jason@norwood.com.