HHS-OIG Releases Medicare Advantage Toolkit to Guide Internal Auditing

As discussed here, the Department of Justice (“DOJ”) has prioritized investigating whether Medicare Advantage (“MA”) plans and providers have submitted unsupported risk-adjusting diagnosis codes, in violation of the False Claims Act.  The U.S. Department of Health and Human Services Office of Inspector General (“HHS-OIG”) has also been active in this space and issued a number of audits of MA plans within the past few years, often focusing on diagnosis codes it characterizes as “high risk.”  HHS-OIG acknowledged that stakeholders “have asked us to share with them how we decided which diagnosis codes were at high risk for being miscoded,” and in response, HHS-OIG issued this toolkit detailing how it has used data analytics to guide its work.  The toolkit offers compliance functions at MA plans and providers a path to assessing whether their coding puts them at risk of government scrutiny.

HHS-OIG used data mining techniques and interviewed clinicians to identify diagnosis codes that were at higher risk for being miscoded.  HHS-OIG first analyzed claims data submitted to the Centers for Medicare & Medicaid Services to identify and isolate relevant risk adjusting diagnosis codes.  HHS-OIG then interviewed clinicians to understand data points that might suggest a higher likelihood of unsupported codes.  For example, through interviews HHS-OIG concluded that many diagnosis codes were more likely to be unsupported if “1) they occurred through a face-to-face encounter with a physician, but (2) that same diagnosis did not occur on an inpatient claim within 6 months (before or after) that encounter.”

The toolkit compiles the high-risk diagnosis code groups identified by HHS-OIG: acute stroke, acute myocardial infarction, embolism, lung cancer, breast cancer, colon cancer, prostate cancer, and potentially mis-keyed diagnosis codes and for each, provides Structured Query Language programming code to assist stakeholders in analyzing datasets.  MA plans and providers could use the toolkit as a starting point to assess their own coding practices for HHS-OIG’s high-risk diagnosis code sets.

This toolkit follows HHS-OIG’s release of a telehealth-specific toolkit earlier this year, discussed here, and highlights an emerging trend of HHS-OIG sharing insights with industry on its own use of data analytics to target potential fraud in areas of priority for HHS-OIG and DOJ.  As law enforcement continues to scrutinize MA diagnosis codes, MA plans and providers may find it useful to engage in their own reviews first.

A copy of HHS-OIG’s MA toolkit is available here.


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