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Doing what’s right is never wrong!

Over the last six months we’ve all read the disappointing stories about some of the missteps (intentional or unintentional) made by some of the major Medicare Advantage (MA) insurers. Both Humana and Anthem did not have adequate or effective safeguards in place to detect claims with faulty diagnoses. However, more recently, the federal government has sued Kaiser Permanente, alleging Kaiser pressured doctors to list incorrect diagnoses on medical records in order for Kaiser’s MA organization to receive higher reimbursements.

The U.S. Department of Justice (DOJ) filed the suit and consolidated allegations made in six whistleblower complaints. Six! The complaints were brought under the False claims Act (FCA). Whistleblower complaints are also known as qui tam actions. 

Qui tam is short for the Latin phrase “qui tam pro domino rege quam pro se ipso in hac parte sequitur,” which roughly translates to “he who brings an action for the king as well as for himself.” A qui tam lawsuit is based on ancient common law that allows a private person, known as a relator, to “prosecute” a lawsuit for the government, in this case as part of the FCA, and receive a reward … if the case is successful.

In this lawsuit, at least two reputable health information professionals lodged their complaints with the federal government. The complaints allege that Kaiser Permanente and their various affiliates defrauded Medicare by submitting diagnosis codes that were unsupported by the medical record, thereby falsely inflating Kaiser’s risk adjustment payments from the government.

MA organizations are being monitored very closely, because participation in this Part C program has been rising; it currently serves approximately 40 percent of the Medicare population. These programs are also known for invoking some unconventional (and could be considered arbitrary) demands on providers that result in delays or denials, including matters such as prior authorizations, inpatient versus observation challenges, principal diagnoses to reduce the DRG payment to the provider, and excessive medical necessity. Each MA organization accrues its revenues from hierarchical condition categories (HCCs). Not accepting a claim from a provider that accurately reflects a diagnosis seems illogical. However, if the physician’s claim captures it, then denying a hospital claim essentially results in “savings” to the MA organization (MAO). Remember, the MAO only needs one claim submitted to the Centers for Medicare & Medicaid Services (CMS) to capture the diagnosis that triggers an HCC.

Day Egusquiza amplified some of the MAO challenges in her recent newsletter, where she shared that each payer gets to determine their definition of an “inpatient.” This means that if payer A defines it one way and payer B another, one of those payers will deny your inpatient stay. We know what disputing an inpatient stay means in terms of resources, time, and delayed reimbursement.

MAOs do have some qualities that should not be overshadowed by the grim comments above. For a very reasonable premium, and in some cases, no premium, MAOs provide comprehensive care for Medicare beneficiaries. Although half of all Medicare Advantage enrollees would incur higher costs than beneficiaries in traditional Medicare for a five-day hospital stay, most enrollees do not require a supplemental plan.

Many MAOs provide extra benefits not available to traditional Medicare beneficiaries. They also employ many professionals. These professionals have an obligation to the plan beneficiaries and their fellow colleagues to identify practices that do not appear compliant or legitimate. These professionals should strive to identify variations that could reflect poorly on their organization or lead to the situations referred to in the opening of my article.

So, all of my commentary boils down to say kudos to the whistleblowers who took the risk, stepped up, and did the right thing – calling out practices that appear unlawful. All providers should join together to take a stand against health insurance giants and any bullying they impose.

It’s time for insurers to put patient care ahead of executive and stockholder compensation or profits. The premiums and HCC payments received by MAOs are fair, and the providers should be paid fairly, too, for the care they deliver for the members of these health plans. And don’t forget, these are the elderly of our population. They deserve to be treated well, to be put on a pedestal. Doing what’s right is never wrong!


Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, is a past president of the American Health Information Management Association (AHIMA) and recipient of AHIMA’s distinguished member and legacy awards. She is chief operating officer of First Class Solutions, Inc., a healthcare consulting firm based in St. Louis, Mo. First Class Solutions, Inc. assists healthcare organizations with operational challenges in HIM, physician office documentation and coding, and other revenue cycle functions.

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