MA Plan Diagnosis Code Games

I am sure by now that many of you have heard the news that there is an ongoing criminal investigation into UnitedHealthcare’s Medicare Advantage (MA) activities.

We don’t know what they are investigating, but it is worth noting that this is a criminal probe and not civil. We have all seen the multitude of audits finding that MA plan reporting of Hierarchal Condition Categories (HCCs) is problematic, and this seems like a possible target, but I would think that to make this criminal in nature, there must be evidence that it was systematic and intentional.

The wheels of justice turn slowly, but perhaps we will know more in the coming months or years.

Moving on, as many of you may know, the advent of the Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractor (RAC) program heralded the launch of this webpage, still titled RACmonitor News. Yet we rarely talk about the RACs anymore. Now, of course, they are still out there auditing, and there are 145 approved issues that they can audit. And in fact, the contract for regions 3, 4, and 5 was recently awarded to Cotiviti, displacing HMS and Performant.

But if you go to the CMS RAC program webpage, you will see that there are four topics that are listed as being under review for inclusion since November of last year.

And that seems strange, so I took a look at the Cotiviti and Performant sites and found that two of those four issues were actually approved in January of this year. Now, perhaps this is a result of the personnel cuts we have been hearing about at the U.S. Department of Health and Human Services (HHS), but it should worry all of us that CMS may be letting the RACs run free without any oversight.

Next, I mentioned the HCC issues with MA plans. The plans do everything possible to maximize their enrollees’ risk scores to maximize their payment from CMS. And it was a mystery to me how CMS gets all those HCC codes. Turns out that when an MA patient is seen, the provider sends the claim with all the diagnosis codes to the MA plan, but also sends a second claim, called a shadow claim, to CMS to obtain the added payments for medical education, uncompensated care, and other add-ons that are not the responsibility of the MA plan.

But the way CMS gets the diagnosis codes to calculate risk scores is different. The MA plans separately submit information to CMS via the Encounter Data Processing System.

Now, here is the key: if you submit a claim to an MA plan for an admission and they come back and do a clinical validation audit weeks, months, or even years later and remove a diagnosis, usually downgrading the DRG and demanding a refund, they are obligated to also submit a correction to the Encounter Data Processing System retracting that diagnosis.

But do they? Maybe it’s worth including a reminder to the plan of their obligation. If that diagnosis is not going to count as a complication or comorbidity (CC) or major CC (MCC) on your claim, it certainly should not be considered an HCC when calculating the MA plan’s capitation payment for that patient. Perhaps it is worth reminding the plan of their obligation when you have a denial.