Medicare Advantage: You have probably heard some industry buzz about the recent investigations (and settlements) into risk adjustment fraud with several of the major insurers. United Health Group along with others, are accused of manipulating diagnosis codes to make patients appear to be sicker to achieve higher reimbursement outcomes via the Medicare Advantage program. Medicare Advantage allows providers to participate in a reimbursement model based on risk adjustment factor. Risk adjustment factor is determined by diagnosis complexity and specificity. Providers who treat patients that are sicker or have more chronic conditions are reimbursed at a higher rate per patient, regardless of actual health outcomes. This all relates back to the importance of understanding the False Claims Act and maintaining an ongoing internal compliance program. If you are still in the mindset of thinking accuracy with regards to reporting diagnosis codes is meaningless – Think Again!
- Are you currently participating in a Medicare Advantage Organization (MAO)?
- When was the last time your practice/providers were audited?
Routine monitoring is required to ensure risk adjustment factor is being properly determined and in alignment with provider clinical documentation! Call us for an audit today!