Is Ambiguity Our Friend Any More? (Redux of July 15)

By Kevin Mowll, Executive Director of the RISE Association

HCC coding is a rigorous and demanding science, as I have learned from the coding workshops RISE has put on for coders. There are admitted “grey zones” where different coders come up with different conclusions on which codes are allowable and which are riskier bets. This ambiguity allows payers with higher tolerances to “sail closer to the wind” when it comes to policy decisions regarding HCC coding. It permits them to harvest more diagnoses and the revenue that they bring, which does all kinds of good things for maintaining rich plan benefits and lower premiums to compete in the market. Isn’t that a good thing? Well, maybe not.

When it comes to walking it all back from the charts in a RADV audit, what will the failure rate be when the tally is done? For the Medicare Advantage program, CMS has yet to announce the long-promised extrapolation penalty and the FFS benchmark, so are these more aggressive plans betting that (a) they will not be tagged among the 30 MAOs audited each year, and (b) even if they are among those being audited, their validation failure rate will not compare so badly to the presumed FFS benchmark?

The stakes around these policy decisions have recently escalated, however. CMS has come under pressure to turn up the heat on MA plans and, in the HIX marketplace, there will be 100% RADV audits for the 2016 plan year. Now CMS has publishes a request for information regarding expanding the RAC program to Medicare Advantage as required under the Affordable Care Act, according to an article in Modern Healthcare by Bob Herman, published at the end of December.


I referred to the following in the July 2015 version of this editorial:  HHS has published a schedule of estimated levels of improper payments for Part C of Medicare Advantage in 2014 amounting to $12.2B or 9% of total payments.  On Part D, this is estimated at 3.3%, adding up to $1.9B. The aim is to recover this amount of money from the MA and Part D plans.

In contrast to previous statements by CMS regarding the plan for RADV extrapolation, it appears to me that these figures presume no FFS benchmarks to dampen the error rate by comparison. It seems that any chart validation error is an overpayment and, consequently, needs to be recovered. Here is a point of divergence between the HHS OIG and the CMS program, which has enormous financial implications for MA plans: zero tolerance for any chart audit discrepancy. That is what the industry had originally feared:  the “nuclear option” for extrapolation, which would be financially catastrophic.

The new news is that, if CMS launches the RAC audits, the privately contracted auditors will be motivated by earning a share of the recoveries on erroneous claims of diagnoses by the plan.  This is enabling the ambiguity factor to be turned in favor of an aggressive auditor at the expense of the MA plan. The opportunities permitted by this ambiguity have now become liabilities.

We operate in an area with certain ambiguities require decisions that draw bright lines where none really exist. While training by CMS in the past has outlined the general framework of what is and is not acceptable, we often find ourselves at a loss for clarity when we get into the particulars. CMS has steered clear of giving guidance on specific instances, instead referring to ICD-9 guidelines and The Coding Clinic for interpretative support. But even so, these resources have not provided the definitive answers to some of the nitty gritty “for instances”.

It is not clear how aggressively the HIX RADV program will be instructing the SVA auditors to be, but the sheer fact that 100% of plans being audited elevates the exposure of every issuer in the HIX space.  Therefore, it seems to me that the need for industry alignment around “best practices” on HCC coding is an imperative.  Comprehensive and consistent training of HCC coders needs to be conducted in order to establish a more uniform approach and standard of practice.  Secondly, it also means that a bottom-up training and education of provider practices in documentation and CDI is also going to be necessary, along with HCC coding information-sharing and guidance. 

In short, rather than establish bright line guidance and training for all those involved in the “food chain” of HCC accuracy, HHS and CMS are taking the approach of auditors and prosecutors, failing anything better or easier.  Under legislative mandate by the ACA itself, this is the course they will take. 

Consequently, it seems that it remains with industry to self-police and transform all the stakeholders’ work practices to come into conformity around a set of best practices.  

Categories: risk adjustment, CMS, HIX
Tags: RADV, HIX, RAC audits, HCC coding

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