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?


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

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