This may come as a shock: The federal government believes some health insurance companies may be exaggerating patient conditions in order to charge more for services. To find out how rampant this odious behavior may be, the Centers for Medicare and Medicaid Services is preparing to launch a beefed-up auditing program of Medicare Advantage patient billing records.
In a lengthy request for information from interested contractors to help carry out the initiative, CMS outlines the problem: Patient diagnoses, it knows, are being intentionally miscoded by insurers to up the level of the patient’s medical problem. But it isn’t sure how widespread the situation has become.
CMS has a formula for assessing such practices: the Risk Adjustment Data Validation, which “measure[s] the extent to which inaccurate diagnosis codes impact HCC assignments and the associated payment for Medicare Advantage beneficiaries. The validation process involves the evaluation and analysis of the risk adjustment data via medical record review,” CMS says in its RFI.
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