Hospital Strongly Objects to MA Plan Audit Methods – Or Do They?

I was fortunate to obtain excerpts from an appeal letter submitted by a hospital in response to a Medicare Advantage (MA) denial from Humana. The audit consisted of a review of a series of charts with diagnoses that led to increased payments. As you will read, the provider disagreed with Humana in many ways.

“Humana’s audit methodology relies on a physician to act as a tiebreaker in situations where two coders disagree on whether a medical record submission substantiates a diagnosis,” the letter read. “We feel that Humana should use the same methodology as CMS (the Centers for Medicare & Medicaid Services) where if a diagnosis appears to be unsubstantiated, the review is escalated to a second coder, and if that coder feels the documentation supports the diagnosis, the diagnosis should be accepted.”

“Second, it is unclear what specific diagnosis coding guidance Humana provides to its staff to interpret, add to, or inform the use of ICD coding guidelines,” the letter continued. “The standards used by Humana could have a substantial impact on Humana’s findings of whether a diagnosis is valid or not.”

“We as a hospital rely on medical providers to generate documentation based on the providers’ clinical judgment and their implementation of a complex diagnosis coding system. We take reasonable steps to ensure the accuracy completeness and truthfulness of the diagnoses they document based on best knowledge, information, and belief, but we do not impose a requirement of 100-percent accuracy. Humana cannot expect us to know that every piece of data is correct nor is that the standard that we believe is reasonable for Humana to enforce.”

“In addition, we note that Humana’s audit simply denies diagnoses, but make no effort to find diagnoses that are clinically present but are not reported by us. These would lead to significant underpayments by Humana that would cancel out much of what is claimed to be an overpayment.”

Oh, oh, wait. Oh my gosh. I totally messed up. That was not what a hospital put in an appeal letter they sent to Humana; it is what Humana stated in a response to a U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) audit of Humana’s Medicare Advantage HCC code submissions for 2018 and 2019. In that audit, the OIG determined that Humana was overpaid over $13 million. And as you can imagine, Humana was not happy, because since the audit was of codes submitted in 2018, extrapolation was allowed, and the OIG used it.

These, of course, are simply excerpts of what Humana argued in their response. The actual response is 16 pages of legal arguments, with Humana trying to argue basically that the rules exist for others, but not for them.

Interestingly, this audit was released just days before Kasier Family Foundation Health News released an article titled, The Medicare Advantage Influence Machine.

I urge everyone to read it.

Opinions expressed in this article are strictly those of the author and not that of R1 RCM.