The Office of Inspector General (OIG) has been finding avoidable coding errors in audits. Now that they have published the 2024 work plan, do you have your response plan ready?
A primary focus of the OIG is to provide financial oversight of Medicare Advantage Organizations (MAOs). In 2022, the federal government spent more than $403 billion on managed care programs with 50 percent of the Medicare enrollees receiving care through MAOs. The Centers for Medicare & Medicaid Services (CMS) pays every MAO a monthly amount for Medicare enrollees based on their medical diagnoses in the form of a risk adjustment payment. To fight fraud, waste, and abuse and protect taxpayer dollars, the OIG conducts health plan audits as a part of its oversight of validating risk-adjusted payments made by CMS. As of August 2023, OIG audits this year had identified approximately $377 million in risk adjustment overpayments based on inaccurate coding.
Uncovering risk adjustment audit findings
In conducting the audits, OIG has identified a few consistent trends in diagnosis errors. Within the Medicare Risk-Adjustment Data-Targeted Review of Documentations Supporting Specific Diagnosis Codes audit, the watchdog targeted specific diagnosis codes utilizing specific logic. For example, Acute Stroke and Acute Heart Attack diagnoses were both pulled into an audit if there was a missing associated inpatient claim, as it is unlikely these conditions would be treated in an outpatient setting. Similarly, Major Depressive Disorder, Embolism, Vascular Claudication, Lung Cancer, Breast Cancer, Colon Cancer, and Prostate Cancer were all also audited as the diagnoses were missing associated medication or treatment claims. From non-targeted OIG compliance audits, we are seeing diagnoses such as Diabetes with Complications, Angina Pectoris, and Morbid Obesity were also either not supported, or not coded to the correct degree of severity.
