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.