- January 17, 2024
- Alerts
OIG Issues Toolkit for Medicare Advantage Organizations
The U.S. Department of Health and Human Services, Office of Inspector General (OIG) released a new toolkit to help Medicare Advantage (MA) organizations replicate OIG audit methodologies to detect and correct inaccurate diagnosis codes in their own systems. This was the third compliance toolkit issued by OIG in 2023, and it highlights OIG’s continued expectations that providers and organizations proactively take steps to reduce improper payments and ensure compliance with applicable health care laws.
OIG routinely performs audits to determine whether MA organizations submitted certain diagnosis codes - ones that when coupled with other data such as procedure codes and prescription drug events – indicate a high risk for being miscoded. In a nod to its growing use of data analytics, OIG identified eight high-risk groups with high error rates and the reasons why these groups are prone to being coded erroneously:
Overall, OIG found that use of these diagnosis codes was unsupported by the associated medical records anywhere from 70 to 90 percent of the time. OIG’s new toolkit shares its Structured Query Language (SQL) — a programming language used in OIG audits, as well as all of the actual codes used in its programming language. MA organizations can use this information to enhance their own auditing and compliance programs as it relates to these eight high-risk groups. MA organizations can also adapt this information to identify other diagnosis codes with high-risk miscoding potential based on their organizational experiences.
The risk of improper payments resulting from inaccurate diagnosis codes is significant and costly, particularly since (1) The Centers for Medicare & Medicaid Services (CMS) monthly payments to MA organizations are based, in part, on diagnosis codes; and (2) CMS pays MA organizations more, on a risk adjusted basis, for diagnosis codes associated with more intensive use of health care resources.
The toolkit provides MA organizations with a new way to bolster their efforts to submit accurate diagnosis codes and to prevent, detect, and correct improper payments. The toolkit is available at: https://oig.hhs.gov/oas/reports/region7/72301213.pdf.
This is also a good time to perform internal auditing of medical records. If you would like to schedule a time to speak to an auditor at our affiliate, Garfunkel Health Advisors, please call 833-355-1333.
Should you have any questions regarding the above, please contact the authors, the Garfunkel Wild attorney with whom you regularly work, or contact us at info@garfunkelwild.com.
OIG routinely performs audits to determine whether MA organizations submitted certain diagnosis codes - ones that when coupled with other data such as procedure codes and prescription drug events – indicate a high risk for being miscoded. In a nod to its growing use of data analytics, OIG identified eight high-risk groups with high error rates and the reasons why these groups are prone to being coded erroneously:
- acute stroke;
- acute heart attack;
- embolism;
- lung cancer;
- breast cancer;
- colon cancer;
- prostate cancer; and
- potentially mis-keyed diagnosis codes.
Overall, OIG found that use of these diagnosis codes was unsupported by the associated medical records anywhere from 70 to 90 percent of the time. OIG’s new toolkit shares its Structured Query Language (SQL) — a programming language used in OIG audits, as well as all of the actual codes used in its programming language. MA organizations can use this information to enhance their own auditing and compliance programs as it relates to these eight high-risk groups. MA organizations can also adapt this information to identify other diagnosis codes with high-risk miscoding potential based on their organizational experiences.
The risk of improper payments resulting from inaccurate diagnosis codes is significant and costly, particularly since (1) The Centers for Medicare & Medicaid Services (CMS) monthly payments to MA organizations are based, in part, on diagnosis codes; and (2) CMS pays MA organizations more, on a risk adjusted basis, for diagnosis codes associated with more intensive use of health care resources.
The toolkit provides MA organizations with a new way to bolster their efforts to submit accurate diagnosis codes and to prevent, detect, and correct improper payments. The toolkit is available at: https://oig.hhs.gov/oas/reports/region7/72301213.pdf.
This is also a good time to perform internal auditing of medical records. If you would like to schedule a time to speak to an auditor at our affiliate, Garfunkel Health Advisors, please call 833-355-1333.
Should you have any questions regarding the above, please contact the authors, the Garfunkel Wild attorney with whom you regularly work, or contact us at info@garfunkelwild.com.