When Health Plans Need an Insurance Policy
The Department of Justice (DOJ) recently reported that they will intervene in the case of six whistleblower lawsuits against a major health plan regarding Medicare Advantage diagnosis codes and alleged Medicare fraud.
The lawsuits allege that the health plan’s process of “coaching” providers to submit ICD data that would require risk adjustment, months and sometimes more than a year after a patient encounter took place, resulted in false claims. They allege that this retrospective workflow resulted in the submission of data that included conditions the patients did not have or that providers did not document during the encounters.
“Medicare’s managed care program relies on the accuracy of information submitted by health care providers and plans to ensure that patients receive the appropriate level of care, and that plans receive the appropriate compensation,” said Deputy Assistant Attorney General Sarah E. Harrington of the Justice Department’s Civil Division in the announcement. “Today’s action sends a clear message that we will hold health care providers and plans accountable if they seek to game the system by submitting false information.”
The health plan commented that they are confident they are compliant “with Medicare Advantage program requirements and (they) intend to strongly defend against the lawsuits alleging otherwise.”
Health plans are in the business of selling insurance, but in the case of mitigating risk of DOJ civil actions they need to buy insurance by investing in computer assisted coding systems that change their workflow. They need to change from a predominantly retrospective workflow process, which is the basis of the government’s case, to a more prospective payment system or a concurrent coding review process that is more accurate and less scrutinized by government auditors.
In our June 7th blog Retrospective Chart Review Raises Concerns with Regulators, we commented on this very same issue. In that blog we highlighted the nature of the disputes health plans have had to defend against government auditors regarding alleged Medicare fraud and abuse.
We reiterate, these actions should be of no surprise to industry insiders since the Office of the Inspector General (OIG) report published in December 2019 questioned the retrospective chart processes and per the OIG, “Billions of estimated risk-adjusted payments supported solely through chart reviews raise potential concerns about the completeness of payment data submitted to CMS, the validity of diagnoses on chart reviews, and the quality of care provided to beneficiaries.”
There have been two major lawsuits where the DOJ has intervened this year, both with the same solution. Do it right the first time. Use artificial intelligence in healthcare, specifically NLP technology to assist physicians with clinical decision support at the point-of-care. Facilitate the selection of the appropriate ICD codes upon the conclusion of an encounter and make it comprehensive and hassle free. Link codes to the text in medical records to make it easier for an auditor to understand why a code was submitted. Plans need to offer providers the Medicare risk adjustment tools to perform concurrent and prospective review, reduce their investment in costly retrospective review, and thereby reduce their liability!
Blog by: The ForeSee Medical Team