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False Claims Act and MAOs: Important Takeaways for Provider Groups

False Claims Act and MAOs: Important Takeaways for Provider Groups

The Medicare Advantage program continues to grow as more and more Medicare-eligible beneficiaries enroll. In 2020, the program provided health care coverage for 25 million Americans, with a total annual cost of $314 billion. The government is increasingly invested in ensuring this enormous budget is properly allocated.

Medicare Advantage Organizations (MAOs) that systemically report false diagnoses can cost the government millions of dollars. As a result, the Department of Justice (DOJ) has identified health care fraud as an important priority for False Claims Act (FCA) investigations. Among other tactics, they’re incentivizing the act of whistleblowing. Whistleblowers who successfully uncover fraudulent practices can be awarded up to 15% to 25% of the government’s recovery for their efforts.

As the DOJ cracks down on the overreporting of diagnoses, the implications will reach beyond the MAOs themselves. Provider organizations may end up having to repay money gained from overreporting. Repeat offenders could find themselves under scrutiny from Centers for Medicare & Medicaid Services (CMS), with frequent audits that can pose a significant administrative burden.

In particular, those organizations that rely on retrospective HCC coding reviews may find themselves under a microscope as the DOJ looks for fraudulent diagnoses added after care has been provided and documented. A recent report from the Office of the Inspector General titled Billions in Estimated Medicare Advantage Payments From Chart Reviews Raise Concerns states, “MAOs almost always used chart reviews as a tool to add, rather than to delete, diagnoses—over 99 percent of chart reviews in our review added diagnoses.” The report goes on to recommend that CMS “conduct audits that validate diagnoses reported on chart reviews in the MA encounter data.”

By implementing concurrent HCC coding programs, provider organizations can capture all relevant diagnoses at the point-of-care and ensure data is both documented in the medical record and submitted appropriately on the claim. The RCxRules HCC Coding Engine can help simplify this process. Our technology reviews every encounter that leaves your EMR in real time. If an encounter does not need coder review, then it automatically passes through to your revenue cycle system in milliseconds. If the technology detects a likely HCC coding gap, then it directs the encounter to a coder for review. This solution helps ensure that encounters are neither over-coded nor under-coded—claims go out correct, every time.

To learn more about our concurrent HCC coding solution, set up a 1:1 meeting today.

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