Anti-Fraud Challenges for 2013 (Presented at HCCA Managed Care Compliance Conference)

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Anti-Fraud Challenges for 2013
Mary Inman
Tim McCormack
Constantine Cannon LLP*
Presented at:
HCCA Managed Care Compliance Conference
February 25, 2013
*At the time of this presentation, Ms. Inman and Mr.
McCormack were partners at Phillips & Cohen LLP.
www.constantinecannon.com

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Anti-Fraud Challenges for 2013
 Audit Scrutiny of Medicare Risk Adjustment
Payments
 Into the Looking Glass – Fraud in the
Affordable Care Act
 Is your compliance program ready for the
2013 Challenges?

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Audit Scrutiny of Medicare Risk
Adjustment Payments

OIG Risk Adjustment Data Validation
Audits
Medicare
Advantage
Organization
(MAO)
CY of
Audit
Date
Published
Dollar Value
(Actual)
Dollar Value
(Extrapolated)
Error Rate
(% Risk
Scores Don’t
Validate)
Charts that Don’t
Validate (/Charts
Audited)
PacifiCare of
Texas
2007 May 2012 $183,247 $115,422,084 43% 43/100
Paramount Care 2007 September
2012
$205,534 $18,216,541 44% 44/100
Excellus Health
Plan
2007 October
2012
$157,777 $41,588,811 46% 45/98
PacifiCare of
California
2007 November
2012
$224,388 $423,709,068 45% 45/100

Systematic Problems
 The MAO did not have written policies and
procedures for obtaining, processing, and
submitting diagnoses to CMS.
 Practices were not effective in ensuring that
the diagnoses MAO submitted to CMS
complied with the requirements of the
applicable Participant Guide.

Specific Coding/Claims Issues
 Risk Adjustment Claims invalid because:
 Documentation did not support the claimed
diagnosis.
 Documentation did not include the provider’s
signature or credentials.
 No documentation was proffered to support
diagnosis.

“Unsupported Diagnoses”
 No documentation that diagnosis affected the care,
treatment, or management provided during the
encounter.
 Taking diagnosis codes from problem lists or other
documentation that merely lists diagnoses with no
indication of evaluation and treatment for each
condition.
 Taking diagnoses from patient histories or history
codes.
 Claiming a diagnosis code based solely on prescription
medication.
 Unconfirmed diagnoses

Diagnosis must affect care, treatment,
or management
 Health Plan submitted risk adjustment claim for
“major depressive disorder, recurrent episode,
moderate.”
 The medical record stated that the patient had
complained of leg pain and difficulty walking.
 OIG concluded: “The documentation did not indicate
that depression had affected the care, treatment, or
management provided during the encounter. “
PacifiCare of Texas at 6

Problem List
 Health Plan submitted risk adjustment claim for “chronic
airway obstruction” (diagnosis code 496 / HCC 108)
 OIG rejected claim, reasoning:
“Problem list with working diagnoses and medications does not
support current treatment for the condition. According to RA
Participant Guide 7.2.4.5 ‘An acceptable problem list must be
comprehensive and show evaluation and treatment for each
condition that relates to an ICD-9 code on the date of service.’ …
Just because a patient has a chronic condition doesn’t mean it
should be coded every time the patient comes in. Report it only
if its relevant to the service provided. “
Paramount at 39

Coding from Patient History
“chronic airway disease, not elsewhere classified.”
 The medical record indicated that the patient’s
complaint was shoulder and back pain.
 OIG rejected claim, reasoning that, although the
medical record indicated a history of chronic
obstructive pulmonary disease, there was no
documentation stating that COPD affected the care,
treatment, or management provided during the
encounter.
Paramount at 6

Coding from History Codes
“prostate cancer” (diagnosis code 185/HCC 10).
 OIG rejected claim, reasoning:
 Medical Review Contractor Comments:
“[H]istory of prostate cancer diagnoses ... does not support
current diagnosis of cancer with active treatment. According
to ICD-9-CM coding guidelines, personal history codes (V
codes) explain a patient’s past medical condition that no
longer exists and is not receiving any treatment but that has
the potential for recurrence and therefore may require
continued monitoring.”
Paramount at 39.

Coding from Prescription Drugs
 Health Plan submitted risk adjustment claim for “Major depressive
disorder, singe episode, moderate.”
 The medical record documented the patient’s condition simply as
"depression.”
 Plan attempted to justify upcoded claim, arguing:
“The patient is noted to have been widowed since February 2006. During the
visit, the physician also notes that the patient is "not coping," is "tearful," and
"not sleeping." During the May 16, 2006, visit, the patient was started on an
antidepressant (Zoloft). In a later encounter on June 20, 2006, the patient is
noted to be "still with depression," and her prescription for Zoloft was adjusted.
Based on this information, the patient's clinical symptoms and treatment course
are clinically consistent with Major Depression.”
 OIG rejected that reasoning, noting that the physician had only diagnosed
depression.
PacifiCare of California at 48.

Unconfirmed Diagnoses
“atrial fibrillation.”
 Patient’s medical record stated: “(?) A-fib,
paroxysmal and ordered a Holter Monitor for
confirmation.”
 OIG rejected claim, citing rule that diagnoses that
are “probable,” “suspected,” “questionable,” or
“working” should not be coded.
Paramount at 7

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Into the Looking Glass – Fraud in
the Affordable Care Act

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Federal Money = Potential FCA Risk
 Direct v. Indirect Government Spending
 Premium Subsidies (Refundable Tax Credit)
 False Claims Act v. IRS Whistleblower Program
 Causing submission of false tax claims?
 Medicaid Expansion
 ?

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Potential Issues With Plan Eligibility
 Medical Loss Ratio
 Cherry Picking / Lemon Dropping
 Mandatory / Promised Benefits

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Is your compliance program ready
for the 2013 Challenges?

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New Frontiers
 Risk Adjustment: Encounter Level Data
 Risk Adjustment: Prospective Assessments
 Electronic Medical Records

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Prospective Assessments
 Medical necessity
 Actual Treatment
 Qualified Provider

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Electronic Medical Records
 Upcoding E/M codes, risk adjustment claims,
etc. through:
 Macros
 Accuracy of auto-fill text
 Leading menus, scripts, etc.
 Cloning text
 Carrying forward text

Anti-Fraud Challenges for 2013 (Presented at HCCA Managed Care Compliance Conference)

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