In recent conferences at RISE National and RA Innovations, the Office of the Inspector General (OIG) has been in attendance to discuss the latest efforts to crackdown on inappropriate risk adjustment coding. All organizations participating in Medicare Advantage (MA) will benefit from monitoring OIG activity through their publicly available Workplan to focus a risk mitigation program.  

Practical Tools for Successful Risk Mitigation Programs

In December 2023, the OIG Toolkit, was published.  It provides all the ICD-10 diagnosis and CPT procedure codes needed to start a risk mitigation program. Identifying inaccurately submitted conditions such as strokes, heart attacks, embolisms, lung cancer, breast cancer, colon cancer, and prostate cancer is as easy as importing the tables from the OIG toolkit into your data environment and evaluating the various sources of ICD-10 and CPT combinations coming in to and going out of your organization.  While some organizations participating in MA seek out large industry vendors with advanced analytic platforms and robust, role-based reporting capabilities, starting a successful risk mitigation program does not have to be a heavy lift. In reality, individuals with basic data querying skills can have a huge impact on identifying areas of opportunity to improve your program. 

MA Data Submissions Red Flags   

Rule Out Diagnoses

Rule-out diagnoses have always been a challenge within risk adjustment programs. Rule-out diagnoses have no place on a final claim, but often slip through the cracks in the vast and complicated world of billing and adjudication. OIG is stepping up their evaluation of this problem by looking at common rule-out conditions and evaluating if that condition is showing on both an inpatient and professional claim.  

Unlinked Chart Reviews

For organizations still taking the easy approach to supplemental data submission by submitting all or most of the conditions found during a chart review without attaching them to a claim, this choice has automatically increased the risk of submitting unsupported diagnoses.  It is highly recommended that a change in strategy is made immediately. Not only are you painting an OIG target on your back, but you could be swaying future policy recommendations by medPAC and CMS by showing the number of conditions found only in a chart review and unrelated to visit with a data trail.

Orphaned Conditions

Health assessments with orphaned conditions - ones only found and submitted through a one-time health assessment - have been in OIG's crosshairs for years. As studies continue to show that one-time health assessments only benefit the payers and possibly inaccurate risk scores, any risk adjustment program must ensure that necessary clinical information is passed to and acted upon by the member's PCP and care team. The true benefit that should be championed through health assessments is aligned utilization and improved quality outcomes to optimize care for health plan members.   

Establish a Strong Risk Mitigation Program

Our team of RADV warriors and risk adjustment experts have created comprehensive risk mitigation programs for some of the largest payers in the country. If you are not addressing any of these OIG focus areas, reach out to us for a free consultation at info@careoneconsulting.com.  We can help you start your program, assess your current program, and align your audit and coding teams on your current protocols to minimize and reduce your audit risk. 

This content was produced by CareOne Managing Partner Jonas Foit. Jonas is a leading risk adjustment expert having created one of the first comprehensive risk adjustment retrospective, prospective, and analytics solutions for the industry. He has created and led operational programs and solutions for varied companies such as Molina Healthcare, Pulse8, Inovalon, Datavant, and Cotiviti.