The Coming Explosion Of Medicare Advantage Fraud And Penalties

Innovation The Coming Explosion Of Medicare Advantage Fraud And Penalties David Lareau Forbes Councils Member Forbes Technology Council COUNCIL POST Expertise from Forbes Councils members, operated under license. Opinions expressed are those of the author. | Membership (fee-based) Aug 19, 2022, 06:00am EDT | Share to Facebook Share to Twitter Share to Linkedin David Lareau is CEO of Medicomp Systems , which makes medical data relevant, usable and actionable.

getty Over the past several years, the U. S. Department of Justice (DOJ) has assessed combined penalties of more than $350 million—specifically, $57.

25 million , $155 million and $145 million —to three vendors of electronic health record (EHR) systems related to the meaningful use programs set up as part of the American Recovery and Reinvestment Act (ARRA) of 2009. The initial funding for the healthcare information technology portion of ARRA was $19. 2 billion , which is dwarfed by the $348 billion paid annually for Medicare Advantage plans—a figure that is expected to grow to more than $600 billion by 2029.

When there is this much money involved, two things typically happen. First, people figure out how to game the system to squeeze the most money out of it. Second, the whistleblowers start reporting fraud a few years later, and the DOJ begins their investigations.

With this in mind, here’s a prediction: The amount of fraud and the resulting penalties related to Medicare Advantage could be far greater than anything we have seen in the past. Some Common Problematic Approaches One way that providers and health plans sometimes look to solve these issues is to “optimize” risk-adjusted payments for Medicare Advantage. For some, the focus is on how to “ upcode ” diagnoses to qualify for higher risk scores and not on how to better manage a patient’s clinical conditions to improve outcomes, which is the original intent of the Medicare Advantage program.

MORE FOR YOU Google Issues Warning For 2 Billion Chrome Users Forget The MacBook Pro, Apple Has Bigger Plans Google Discounts Pixel 6, Nest & Pixel Buds In Limited-Time Sale Event One approach is to bring in claims data, look for diagnosis codes that did not qualify for risk adjustment and to suggest other codes that would qualify. Also, be wary of this approach and also of “ upcoding engines ” to generate additional money into their risk pool, which is sometimes referred to as “suspecting” or “prospecting,” bringing to mind the image of a gold miner digging for riches. Why Proper Documentation Is Always The Best Answer There is a coming gold rush related to value-based care, and it may end badly for those who do not make sure their care of the patient, and the documentation thereof, complies with Medicare Advantage requirements.

The requirement is this: For each diagnosis that is claimed for risk adjustment, the patient must be seen during the current plan year and the medical record must reflect appropriate management, evaluation, assessment and treatment for the diagnosis. It is will not be enough to simply pick a code and be done with it. The clinical documentation must support the diagnosis selected and show that it was appropriately assessed and treated.

Merely picking a more specific code is not going to cut it at all when the auditors come calling. With so much money at stake, expect the DOJ to come down hard on the offenders. The Civil Monetary Penalties Law ( 42 U.

S. C. 1230a-7a ) says the Office of the Inspector General may seek penalties ranging from $10,000 to $50,000 per violation Compliance will require that the care provided, and documentation thereof, supports the codes selected.

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