The government is increasing enforcement efforts around proper risk adjustment coding (HCC coding).  We continue to see regular audit reports detailing significant overpayments due to improper reporting of diagnosis codes.

The U.S. Attorney’s Office recently announced a $172,294,350 False Claims Act settlement with Cigna.  Like many other recent cases, the allegations involved the submission of inaccurate diagnosis codes for Medicare Advantage enrollees.

The OIG has also published two new audit reports involving Aetna and Health Net.  Both reports contain findings of overpayments due to reporting of inaccurate and unsupported diagnosis codes.

The OIG identified HCC coding as a top priority earlier this year.  This combined with the Medicare Advantage Risk Adjustment Data Validation Final Rule sets the stage for continued audit activity and record setting overpayment recoveries.

Ensuring appropriate provider documentation and accurate HCC capture and reporting should be a top priority for all compliance professionals.  If you have not added HCC audits to your compliance work plan, now is the time.

To read more about the Cigna settlement: https://www.justice.gov/usao-edpa/pr/cigna-group-pay-172-million-resolve-false-claims-act-allegations

The OIG audit reports are available here: https://oig.hhs.gov/reports-and-publications/oas/cms.asp

We are here to help.  The HBE team is available to assist you with all of your clinical documentation, coding and compliance program needs.  We routinely provide compliance partner services to large health systems as well as physician practices. Our services include:

• Clinical documentation improvement reviews
• Risk Assessments
• Coding accuracy reviews
• Policy and procedure development
• Customized education and training for clinical and administrative staff