Capitated Doc Is Indicted in First MA Upcoding Criminal Case in S. Fla.

If you have been sleeping under a rock, you may not be aware of this risk adjustment legal case in Florida.  Otherwise, you are wondering how it will turn out and what it will reveal about what really went on in Del Rey, Florida. The question is really about what was done by whom, where were legal lines crossed and who all is going to end up paying the piper.  

The indictment states that this is an alleged case of fraud at the level of a particular provider's two offices.  The provider had been operating under a capitated risk arrangement through one of the largest MA plans in the country.  My understanding is that the contention is that there was intentional upcoding of ICD-9 codes to inflate the upstream CMS premiums paid to the MAO which then filtered down to the provider on a member-specific basis, generating inappropriately high payments in the revenue stream.  The actual health care conditions were deliberately exaggerated, according to the U.S. Attorney's Office, and the excess funds were not dedicated to payment for health care for the members but rather were diverted to personal use by the provider. 

According to the brief article from Medicare Advantage News, the DOJ is silent about their opinions regarding the liabilities of the upstream MA Organization.  Hence, the watchful waiting.  

As the RISE Association, we are interested in collaborating with our members on putting together a set of standards and best practices for MA healthplans to follow in order to have a practical and robust risk mitigation program for their risk adjustment efforts.  There is no place for the "head-in-the-sand" strategy.  Nor is there a practical option of "doing everything everywhere that might conceivably avoid exposure to risks".  But there is such a thing as creating a program that is keyed off the existing guidance, and continuously improved as more information becomes available.  Stay tuned for more in this theme.  Please contact Kevin Mowll, Executive Director of RISE, if you have any suggestions or comments:  kmowll@risehealth.org

 

http://aishealth.com/archive/nman022615-05

 


Log on to Your Rise Account

Forgot your password?
Create an Account

Sponsors

Latest Posts

CMS Gives EDPS Transition Some Breathing Room

CMS published the final call letter for 2018 yesterday, April 3, which included a welcome accouncement regarding the transition from RAPS to EDPS-based RAF scores. Citing numerous public comments on the subject, CMS throttled back the speed with which they plan to switch over to an encounter-based methodology. Instead of the blended rates originally contemplated, they announced that the more modest blend of 85% RAPS to 15% EDPS would be used in 2018, allowing more time to improve the reliability of the encounter data methods. While the RISE data collaboration study was not cited, we believe that the educational value of our study, along with our communication and advocacy of a more moderate approach by CMS, contributed to the confidence with which plans and other interested parties spoke up during the open comment period. Once again, we owe thanks to the folks at Avalere and Inovalon, as well as at AHIP, for the collegial and professional collaboration. Also, we want to thank the health plans that actively participated in our study for making this work possible. ...
Read More

Take Aways from RISE Nashville Summit

The 11th Annual RISE Nashville Summit continued the event’s tradition of yearly growth. The return to downtown Nashville was widely applauded by attendees, who were glad to be back near Broadway’s nighttime funk and fun. While festive, this year's event occurred in the wake of the new administration in Washington, D.C., and the healthcare themes surrounding the "repeal and replace" of the Affordable Care Act (ACA) cast a long shadow. In contrast to the upbeat, confident notes struck by last year’s keynote speaker Senator Tom Daschle, this year’s sobering keynote address by Howard Fineman, NBC/MSNBC political analyst, The Huffington Post Media Group global editorial director, and bestselling author, was an assessment of the pluses and minuses of our new president. Mr. Fineman's remarks indicated that the political alliances in power will seek to undo what Senator Daschle viewed as "irreversible” a year ago....
Read More

Upcoming Conference

 

Qualipalooza: The 2nd Annual RISE Quality Leadership Summit 

This unique event incorporates three conferences presented side-by-side: the Star Ratings Strategic Planning Forum, the HEDIS Forum, and the CAHPS, HOS & Member Survey Forum. Register for one conference for an in-depth examination of a single area, or design your own event by opting for the all-access pass and choosing the sessions from each conference which correspond exactly to your interests.

More

Upcoming Webinar

The Impact of Quality Incentive Models in Medicaid Markets

 

Thirty-one of our fifty states now have Medicaid managed care, and several markets are expected to implement managed care in the next few years. More than $160B in Medicaid spending occurs through the Managed Care Organizations. As more and more states seek to do more with less, increasing accountability for health quality outcomes is placed on health plans. Join this webinar to learn the typical quality payment approaches states use, issues often faced by health plans under each model and what states are expected to do with payment models tied to quality performance in light of near term Medicaid reform efforts.

More

Connect With Us

Copyright © 2014 Resource Initiative & Society for Education. All rights reserved.