Robust Outpatient Clinical Documentation Integrity (OP CDI) programs include establishing policies designed to review select diagnoses that the Office of Inspector General (OIG) has determined to have been historically overpaid. By establishing a policy to review these diagnoses, denials will be minimized, and institutions and providers will be less exposed to potential fines from inaccurate claim submissions.
In addition, pre-bill reviews will provide an additional means for provider education targeting suspect providers to cease future inaccurate coding, while at the same time, contribute to the impact as a result of accurate documentation practices.
Bombshell Report Leads to Increased Diagnoses Scrutiny
In a recent publication by RISE, the Wall Street Journal reported, “Medicare Advantage (MA) insurers were paid $50 billion from 2018 to 2021 for thousands of questionable diagnoses. The bombshell report revealed that many of the diagnoses that insurers added to patients’ medical records were for conditions in which patients received no treatment. One example cited in the report was for diabetic cataracts, where the investigation found that 66,000 patients were diagnosed with diabetic cataracts even though they had previously undergone cataract surgery.” It’s important to note that cataracts do not grow back once they’re removed. The Wall Street Journal reported in their analysis, “One payer, UnitedHealthcare, was paid $8.7 billion in 2021 for the insurer-added diagnoses.”
“Lawmakers and federal watchdog groups have had MA under the microscope for improper practices,” Inspector General Christi Grimm stated at Rise National 2023. “Of the 17 audits the Office of Inspector General conducted since 2019, there was no support for nearly 69 percent of diagnoses used for risk adjustment, which led to over $100 million in overpayments to MA plans.” Grimm said her goals for 2024 were crystal clear: “to ensure RAF payments are accurate both for the program and the wellness of beneficiaries.”
How to Prevent Upcoding at Your Healthcare Organization
The main way to prevent upcoding is to build a policy to review diagnoses so denials will be reduced, minimizing exposure to potential fines from inaccurate claim submissions.
If your organization doesn’t have the bandwidth or expertise to build a policy, Harmony Healthcare can help.
We are experts at building Clinical Documentation Integrity (CDI) programs for clients. Our team develops the policies, procedures, workflows, and metrics to establish CDI review of select diagnoses. Protect your organization from potential fines from the OIG. Connect with our team today!
