Minimize Compliance Risk:  qrcAnalytics Assists Medicare Advantage Organizations 

By Kathy Ormsby, CPCO, CPC

qrcAnalytics Director of Risk Analytics and Compliance

The Center for Medicare & Medicaid Services (CMS) contracts with Medicare Advantage Organizations (MAOs) and pays Medicare Advantage (MA) plans for managed health care based on a monthly fee per member. The payment is based on the future health care needs and the sickness burden of its members. MA is an alternative to the traditional fee-for-service Medicare.

CMS paid MAOs approximately $200 billion for care in 2016 alone according to the U.S. Government Accountability Office (GAO). CMS estimated that approximately $16 billion, nearly 10% of all Medicare Advantage (MA) payments in 2016 were incorrect. These payments vary based on the health status of the enrolled beneficiaries. Incorrect payments arise from diagnoses that are unsupported in clinical documentation. To identify and recover improper payments, CMS conducts risk adjustment validation (RADV) audits of prior payments. The RADV determines if the diagnosis data submitted by MAOs are supported in clinical documentation.

Medicare Advantage plans are getting a lot of attention, undesired by payers. False Claims Act cases and settlements are becoming commonplace. Chief Counsel to the Inspector General, Gregory Demske of the HHS Office of Inspector General said his office will continue to make sure “Medicare Advantage insurers…play by the rules and provide Medicare with accurate information about their provider networks and their patients’ health.”

CMS requires MA plans to develop and follow an effective compliance program and meet the CMS mandated obligations outlined in the Medicare Managed Care Manual. Having an MA compliance program is one of the conditions of the contract with CMS. The MA organization should have written policies and procedures that include routine monitoring, auditing, and standards that describe the organization’s commitment to comply with all Federal and State laws and compliance expectations.

So, what should MA plans do to ensure compliance?

Most MA plans use outdated coding methods or those used in the fee-for-service coding and auditing program. This does not work with the specificity and clinical validation necessary and used in the submitted MA data. MA plans would be wise to invest in a newer more sophisticated risk adjustment technology solutions that tie in coding results, clinical risk factors, clinical-based evidence, patient outreach, and historical detailed data comparison that:

  • Leverage coders’ feedback and target provider educational opportunities
  • Utilize technology-enabled platforms that allow coders to flag diagnoses that are not appropriately documented in the medical record
  • Analyze coding activity to identify specific clinicians that frequently “under-document”
  • Use historical data to identify specific coding patterns and compliance gaps
  • Benchmark and monitor clinicians for accuracy

MA plans should evaluate their risk adjustment practices to identify any problematic methods currently used and detect areas where technology can expand these efforts. In taking these necessary steps, you will ensure that your clinicians are continually pushed to document and code accurately, therefore fewer compliance red flags will slip through the cracks. The end result supports compliant processes and procedures and the MA plan will ultimately avoid penalties, fines and a loss of reputation. The investment in time will not only improve risk adjustment accuracy but will also support better, more efficient care for the patient and at the same time, will fulfill your obligations outlined in the Medicare Managed Care Manual.

About qrcAnalytics

qrcAnalytics is a healthcare technology company with a state-of-the-art analytic platform designed to improve healthcare delivery, providing insights from coding results, clinical documentation, administrative data, and clinical results. qrcAnalytics leverages proprietary algorithms that aid clinicians, coders, and the entire risk adjustment program to more accurately and efficiently perform program responsibilities supporting Medicare Advantage programs.

qrcAnalytics Auditing Tool highlights:

  • Establish and store encounter documentation and coding results for use in a RADV audit
  • Review the organization’s predetermined sample or all encounters to reduce the submission of unsupported diagnoses codes
  • The capability of “looking both ways” for non-compliance and revenue opportunities
  • Identify coding patterns and educational opportunities for providers and coders