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Improper Payments in Government Programs: Has The Other Shoe Already Dropped?

Updated: Apr 3

Co-Authored by Betsy Seals, CEO and Martha Goodlin, RN

Over the past several years, we have seen an increase in CMS, OIG, and DOJ activity around recouping “improper” payments in the Medicare Program. With the new administration, the focus on identifying and recouping improper payments is almost palpable.

Most recently, on August 30th, the DOJ and Sutter Health settled on Sutter paying $90 Million to Settle False Claims Act Allegations of Mischarging the Medicare Advantage Program.

From a big picture perspective, the risk adjustment landscape and government focus on recouping improper payments has been an evolving process, which has of late, become an item that Compliance Officers and Health Plan Executives are putting increased focus on – specifically focusing on strategies to increase “proper” payments as well as mitigate compliance risk.

Here are five questions for Health Plan Executives to ask Risk Adjustment and Compliance Teams to gauge strategic maturity and compliance risk:

1. What are our strategies for both gap closures and risk mitigation?

Closing gaps and mitigating risk are both equally important in a successful risk adjustment program.

Health plans use analytics to gather data for gap closure to ensure revenue optimization, but it is equally important to use that data to identify areas where they are at risk of inaccurate CMS submissions.

2. Are we performing random and targeted quality audits appropriately?

Is your organization performing both a random sampling and targeted audit of your CMS HCC submissions? Risk adjustment coding is complex, and regular auditing will identify areas where your organization is most at risk for inaccurate coding and submissions.

3. Using the OIG Audit protocol, how would we perform in the event of an actual OIG Audit?

Through data mining techniques, the OIG has identified and targeted diagnoses that are at higher risk of being miscoded. Is your organization performing mock audits using the same analytical strategy to determine the accuracy of your CMS submissions?

4. Are we using chart reviews to not only add but to delete diagnosis codes that are not supported by the medical record?

The expectation from CMS is that diagnoses submitted are accurate and can be supported. When your organization performs retrospective medical record reviews, are they “looking both ways” to ensure that they are not only adding additional diagnoses but also reviewing previously submitted diagnoses and deleting those that are not supported?

5. Do we have stop-gap measures in place for high-risk error codes?

You have done your due diligence, completed random, targeted, and mock audits but have identified certain diagnosis codes and/or providers that are still submitting certain diagnoses inaccurately. Now what? Has your organization implemented appropriate stop-gap measures to ensure that a medical record review is completed prior to submission in order to mitigate your risk?

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