In June of this year, the House Committee on Energy and Commerce held an oversight hearing on Medicare Advantage (MA) plans. Witnesses confirmed instances of “upcoding”––exaggerating patient illnesses to artificially inflate monthly payments from the government––by MA plans. The resulting report revealed upcoding accounted for $12 billion in additional payments in one year alone.

Fast forward to October, and the U.S. Department of Justice filed a civil healthcare fraud lawsuit against Cigna and its subsidiary Medicare Advantage Organizations, seeking damages and penalties under the False Claims Act following allegations the insurer defrauded Medicare out of tens of millions of dollars by upcoding.

This is just the beginning of what will prove to be a lengthy, revealing, and expensive period for some health plans.

For several years, diagnosis coding applications have been available to assist providers and coders in identifying opportunities to choose codes that qualify for higher reimbursement. The software can prompt the user to code a more serious or complex diagnosis; for example, one with complications or higher risk.

However, if the patient does not actually have the more complex condition, and the documentation does not reflect evidence and treatment of that condition, the resulting upcoding can lead to civil fraud allegations if discovered in an audit.

Another capability provided by these coding and analytics applications is automated reviews of a patient chart to identify conditions or diagnoses that might quality for higher reimbursement. A commonly used term for this process is “suspecting.” The purpose is to find conditions and record a diagnosis code that will produce additional revenue. As with upcoding, this should be about managing a condition and documenting its assessment, evaluation, and treatment.

Unfortunately, all too often the focus is on the coding of the condition (real or not), and not the caring for the patient. The troubling trend is being noticed and covered widely in the mainstream and trade press (including a recent piece by Medicomp Chief Medical Officer Jay Anders), and will no doubt lead to many more actions by the Department of Justice.

Medicare Advantage and similar value-based care initiatives are designed to reduce the long-term costs of providing care to patients with chronic conditions. Providing capabilities to merely identify and code a condition, without the tools to manage, evaluate, assess, treat, and document, the care provided is not enough. Again, the focus needs to be on the caring rather than coding.

Despite all the marketing noise to contrary, electronic health records (EHRs) remain little more than static repositories of information that do more to justify diagnoses and billing than to empower clinicians to improve patient care. To improve the care and outcomes of chronic conditions, a new set of tools for clinical management of patients at the point of care is needed. In addition to being able to select a proper diagnosis code, this new set of tools should include:

  • Diagnostically relevant prompting of documentation requirements for each diagnosis that reflect acceptable management, evaluation, assessment, and treatment of each specific diagnosis.
  • The ability to click on any diagnosis and filter the patient record for the “hallmark” indicators and status of that diagnosis, including symptoms, history, physical exam findings, test orders and results, therapies, and evidence of sequalae and complications related to the diagnosis. This will make management of the condition much easier for the provider.
  • A diagnostically focused longitudinal view of clinically relevant information for the condition.
  • Presentation of all other actions needed to satisfy compliance requirements for E&M coding, clinical quality measures, and enterprise guidelines for specific clinical situations.

It is long past time to transition from the view of the patient medical record as an inert platform for coding and billing, to a diagnostically interactive tool to enable and coordinate better patient care. Too many stakeholders have been focused on the wrong issues for far too long.

MA plans reward providers for the successful management of clinical risk and the delivery of cost-effective care, so providers must proactively identify their at-risk patients and deliver appropriate care to ensure optimal outcomes, as well as accurate reimbursement.

But success can be challenging. The intricacies of risk assessment and the need to comply with complex documentation and coding requirements is complicated and resource intensive. To help providers meet these requirements and qualify for accurate reimbursement, Medicomp offers Quippe HCC Risk Optimizer.