DOJ investigating MA Plans

Author: Peter Bechtel, President/CEO WellTrackONE Corporation, April 6, 2017

An article was recently published in FierceHealthCare1 with the title line:

DOJ joins second Medicare Advantage fraud lawsuit against UnitedHealth over risk adjustment practices

The gist of the article focuses on the Department of Justice’s delayed investigation into United Health’s practice of retrospective coding of Medicare risk adjustment codes.  The article says:

The Department of Justice has joined another lawsuit that accuses UnitedHealth of fraudulently inflating its Medicare Advantage risk scores to maximize reimbursement.

A court document (PDF) filed Friday indicated that the DOJ will intervene in a suit that whistleblower James Swoben brought against UnitedHealth, which accuses it of conducting biased retrospective reviews of medical records aimed at boosting its MA reimbursement.

HealthCare Partners is also named in the fourth amended version of Swoben’s suit, which he first filed in 2009, though the DOJ is not currently intervening against the physician group and its affiliates.

To be fair, UnitedHealth does not believe it has violated any laws: “UnitedHealth is ‘confident we complied with program rules,’ spokesman Matt Burns said in a statement to FierceHealthcare2

As anyone who has a good understanding of Risk Adjustment codes knows, Medicare Advantage Plans (MAPs) live and breathe by accurate and clinically-justified use of these codes.  Medicare will pay MAPs more on a per member per month (PMPM) basis if the justification is solid – meaning the patient has been coded with more complex diagnoses that indicate a need to provide a higher (and more expensive) level of care.

A “system” was devised by CMS to help MAPs categorize the coding more accurately – known as HCC or Hierarchical Coding Category.

Risk Adjustment and Hierarchical Condition Category (HCC) coding is a payment model mandated by the Centers for Medicare and Medicaid Services (CMS) in 1997.  Implemented in 2003, this model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual’s health conditions and demographic details.  The individual’s health conditions are identified via International Classification of Diseases – 10  (ICD –10) diagnoses that are submitted by providers on incoming claims.  There are more than 9000 ICD-10 codes that map to 79 HCC codes in the Risk Adjustment model3.

All this makes perfect sense.  But most MAPs don’t have a good way to have their providers code more accurately at the point of care (POC).  Instead, what some MAPs have done is hire coding professionals who go back through the charts “retrospectively” and find backwards-facing justification for Risk Adjustment codes that were not present at the POC but instead, are now being added in later – AFTER the visit.

So, the begging question:  What is a MAP to do to get around this problem and avoid having the DOJ sniffing through its records?

We suggest a cleaner and more clinically-sound practice known as “Prospective Risk Adjustment” coding that is done at the Point of Care.  This is truly how the system was designed in the first place.  However, a “Prospective Risk Adjustment” system must be easy, otherwise it will never be used by the physicians (thus the problem that UnitedHealth may be is facing now).

Some EHR systems have Prospective Risk Adjustment coding built into their coding modules.  Where this is available, the physicians are reminded of “potential” ICD-10 codes that could help with Risk Adjustment increases.

However, the majority of physicians who operate under a MAP do not have such a system in their EHR and the MA Plans need a way to help these physicians with better Prospective Risk Adjustment coding.

WellTrackONE advocates a strenuous (but easy to administer) program of regular annual wellness visit (AWV) evaluation for MA patients.  This gives the MAP valuable data for 5-Star Certification but ALSO provides a perfect time to promote “clinically necessary” Risk Adjustment codes to the physician that are in-line with the patient’s risk factors.

In the WellTrackONE Annual Wellness Visit system is a built-in Decision Support System (DSS) called “Clinical Triggerstm.”  Clinical Triggers run AFTER the AWV is complete and renders suggested preventive services, labs, procedures, treatments and referrals that are “in-line” with the patient’s risk factors.

Clinical Triggers ALSO was developed to promote Prospective Risk Adjustment codes to the physician and does this by putting the codes in the physician report under a category called “Medical Decision Making.”  This gives the physician a quick reference to relevant and clinically indicated Risk Adjustment codes that they may consider for additional workup with the patient.

We preface this cautiously at all times by saying that the physician should “consider” the Risk Adjustment codes.  The physician is always the final decision maker and our Clinical Trigger Risk Adjustment codes are simply suggestions to help the physician at the Point of Care.

An example of “clinically necessary” Risk Adjustment codes would be as follows:

A patient presents for the AWV and is determined to have a severe risk of cardiovascular disease.  A suggestion to the physician would be to evaluate the patient for peripheral arterial disease (PAD).  That HCC code is 108 and the ICD-10 is I73.9.  Naturally, the physician must be as specific as possible with the ICD-10 code but we provide a starting point for the coding through our Clinical Triggers.

We believe that MA Plan physicians, if given a tool like Clinical Triggers, would (1) code better, (2) provide real-time Point of Care codes that are “prospective” instead of “retrospective” and (3) provide better care for their patients.

The stakes for such Prospective Risk Adjustment coding are tremendously high for MA Plans:

1. Their PMPM reimbursements will justifiably go up because the physicians are documenting that they are taking care of more complex patient cases.  This can make a difference in multiple millions of dollars of revenue for the MA Plan;

2. The patient care will be better because patients are diagnosed in advance of having a catastrophic chronic or acute onset (thus the “Prospective” side of the argument); and

3. The DOJ will find the process very satisfactory and in-line with CMS requirements.

In our view, EVERY Medicare Advantage Plan should consider a solid AWV system with a Decision Support tool such as Clinical Triggers for EVERY MAP patient, every year.


1. Article in FierceHealthcare by Leslie Small, March 29, 2017
2. Ibid

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