Following Up on the 2016 CMS Advance Notice

Mintz Levin Alerts MA Organizations About Fraud Risks 

In the article written by Tara Swenson of Mintz Levin and published in the National Law Review recently, there are some worthwhile points to note.  First, CMS is now viewing the population of Medicare Advantage members as being no different than those beneficiaries in Original FFS Medicare, on the whole.  Therefore, the logic goes, the aggregate payment level show be equivalent to the "old school" AAPCC model used before the year 2000 (BIPA era, for the old schoolers).  

Second, CMS has moved to establish two critical pieces of policy regarding in-home assessments in order to tackle potential abuse on the part of MAOs that might try to solely mine for revenue without taking care of the healthcare conditions they might uncover in the visit.  One piece is the publication of the CDC model health risk assessment form as the recommended model for 2016.  The other piece is the publication of "best practices" in terms of follow-up treatnment, evaluation, management or consideration that affects the providers' care of the patient.  With these two tools, CMS hopes to drive monitoring, tracking and reporting to evaluate the legitimacy of the in-home program.  

Finally, Ms. Swenson goes on to suggest a linkage to the Department of Justice, FBI and OIG action against a capitated physician in Florida who allegedly "upcoded" diagnoses in order to boost his financial take home for patients under contract from a Medicare Advantage plan.  

It is worthwhile to read, digest and ponder the warnings that Ms. Swenson posted in this article.  The critical questions will have to be answered by every MAO: 

  1. Are the diagnoses we are capturing and reporting going to pass the validation test by CMS standards?  This includes not only actions by the MAO itself but those taken on behalf of the MAO (e.g., providers and vendors) 
  2. Do we have the mechanisms in place to monitor, report and track the in-home cases, as required, and their logical extensions into follow-up in the doctors' offices?  Will those charts reflect documentation that substantiates the diagnoses captured and reported as would be the case in a RADV audit? 
  3. In the process, are we also "looking both ways" and deleting diagnoses that do not validate and meet the threshold established?  
  4. Overall, what are we doing to ensure that our providers know how to properly document in order for proper validation to take place? 

http://www.mintz.com/newsletter/2014/Advisories/4479-1214-NAT-HL-MLS/

 


Categories: Risk Adjustment
Tags: advance notice, CMS, OIG, RADV

Log on to Your Rise Account

Forgot your password?
Create an Account

Association Sponsors

Latest Posts

Keep M.E.A.T. on Your List for a Healthy Audit

By Jeanmarie Loria, Advize Health, LLC If you’re reading this article, chances are you already know what HCC Coding is – but we’ll give you a refresher anyway. Hierarchical Condition Category (HCC) and Risk Adjustment Coding is a CMS-mandated payment model. This model works to identify those with chronic and other serious illnesses and prescribes a risk factor score to each patient, taking into consideration their ailments and other demographics. With every payment model comes a specific set of audit and review requirements that must be met to maintain the integrity of the system, and this is where MEAT (Monitor, Evaluate, Assess/Address, Treat) comes in handy. In a face to face visit M.E.A.T. maybe found in the chief complaint, history of present illness, review of systems, physical exam, assessment and/or plan....
Read More

Getting It Right: True North in Healthcare Reform

The movement to repeal and replace "ObamaCare" created so much political noise that clear thinking has been hard to come by. The 2010 legislation that created the marketplace for individuals and small business (the Affordable Care Act or ACA), has almost evolved into a political Rorschach test. The more that politicized options and alternatives to repealing, replacing, or repairing it were discussed, the harder it was to put into focus the original problems the legislation was designed to address. Nevertheless, the rancorous divisions over what needs to happen to fix problems in the individual insurance market remain a distraction from the real issue at hand: the cost of healthcare weighing down the economy and what we need to do to fix it. With all the intense debates swirling around this topic, an impression emerges that “solving the ObamaCare issues” is something that must be accomplished as an isolated matter, discrete and independent of other problems. The heated debates concentrate on the mechanics and tactics required to solve the "uninsured problem", the "under-insured problem", and for some, the federal budget problems created by the subsidies for low-income enrollees in these plans. This single-issue mono-vision obscures a reality that must be addressed. This perspective completely misses the fact that something is going on that is far more corrosive to the wellbeing of all of us as consumers of health care, as taxpayers, and as a nation: something that overshadows the tug ‘o war over ObamaCare. The critical and overlooked issue is that health care expenditures in the U.S are at least twice as expensive as other nations, which consume so much of the national economy...
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

Successful and Meaningful Techniques for Integrating Risk and Quality Interventions

Quality measurement and risk adjustment regulations are increasing and the financial impact upon health plans is progressively driving accountability and influencing profitability through payments, penalties, and bonuses. To improve performance and optimize risk and quality payments, Health Plans need to streamline processes, employ best practices for data capture, and focus on strategic interventions that use a member-centric approach.  

Connect With Us

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