Revenue Integrity Obligation in the Risk Adjustment Environment

by Rose T. Dunn, MBA, RHIA, CPA, FACHE

In case we need another reason to stand firm when documentation and/or coding become questionable, we are reminded that not only is it our duty, we may be subject to financial penalty if we do not.

Earlier this year, Becker’s identified the failure of Medicare Part C (Medicare Advantage) to perform its duty to validate the coding (and resulting HCCs) it has submitted to CMS, and for which the Medicare Advantage Organization was paid by CMS. (Becker’s Hospital Review “Anthem hit with federal lawsuit alleging Medicare fraud”.)

Those of us working in the risk-adjustment environment are responsible for ensuring the accuracy of the codes assigned to our claims. This is our revenue integrity obligation: ensure the coding on the claim is adequately supported by the documentation in the patient’s records.

We also need to take the next step to identify variations that may indicate that providers are gaming the system and exaggerating the documentation to include conditions that are absent or not as severe as implied. (See my recent article “Monitoring is Key to Guard Against HCC Gaming”.)

This piece of our compliance obligation is challenging for coding professionals, but it doesn’t preclude us from surfacing ‘weird’ findings to the Chief Medical Officer and Chief Compliance Officer of the organization for which we work.

Finally, when a Medicare Advantage Organization is ‘dinged’ by CMS, we should expect that the Medicare Advantage Organization will trigger a clause in our contract with them to claw back payments to us for those cases that were identified by CMS as inaccurately coded. Depending on the contract language, the claw back could be substantially higher than the fees we were originally paid.


HCC: Auditing in the Risk Adjustment Environment
Internal HCC auditors: get the essential information you need to ensure your organization receives proper reimbursement — and that codes and claims are supported by clinical documentation.

Learn what to look for and how to communicate your findings. Tips and techniques offered by nationally recognized HCC authority Rose T. Dunn! Learn more here.

About the Author

Rose Dunn
Rose Dunn is the Chief Operating Officer at First Class Solutions, Inc., a healthcare information management leader since 1988. Rose is the author of “The Revenue Integrity Manager’s Guidebook” available from the National Association of Healthcare Revenue Integrity and other books on Coding Management and Auditing from HCPro. She engaged herself in ICD-10 more than 10 years before it was implemented. She is assisting Libman Education in the development of an HCC educational program. Rose holds a BS and MBA from Saint Louis University.

One thought on “Revenue Integrity Obligation in the Risk Adjustment Environment

  1. Deborah Gardner Brown - August 28, 2020 at 1:09 pm

    Great Topic Rose!