At 3Gen, we’ve talked for a while about the growing importance of risk adjustment coding—and our rationale is being proven true.
Part of the OIG’s responsibility is conducting health plan audits of Medicare Advantage organizations to identify fraud and reduce waste and other abuses of this taxpayer-funded program. The government spends more than $403 billion every year on managed care, and half of that goes to Medicare Advantage Organizations. The issue is, that as of August of last year, their audit had identified around $377 million in risk adjustment overpayments—and this number was for inaccurate coding alone [1].
This means that providers should expect more audits coming in the future—and a smart response is to get ahead of this by adjusting your approach to risk adjustment coding.
Most providers will need to focus on coding to the highest level of specificity for chronic conditions and consider coding reviews by certified risk coders to ensure accuracy. But if you want to stay ahead of the OIG, this is just the beginning.
- Make it a priority to review your current tools and workflows, looking for opportunities to supplement with outsourced risk adjustment coding where possible.
- Take time to review your health risk assessments. This will help you make sure that the diagnoses you’re billing match what patients are being treated for.
- All of these suggestions rest on the need to analyze your claims data. This will give you a strong starting point for evaluating your practices and charting a path forward.
Ultimately, the OIG is cracking down on overpayments, so prioritizing risk adjustment coding is a smart strategic focus for all impacted providers in the near term. To learn more about how your organization can build a proactive risk adjustment coding strategy, contact 3Gen Consulting today.
Reference
[1] “OIG Strengthens Oversight Strategy for Managed Care Organizations,” Healthcare Payer Intelligence, 08 August 2023. Available: https://healthpayerintelligence.com/news/oig-strengthens-oversight-strategy-for-managed-care-organizations.
Hemant Apte, Chief Executive Officer in
Hemant Apte, Founder & Chief Executive Officer of 3Gen Consulting, is a seasoned executive leader with deep domain expertise in US healthcare management practices. He founded 3Gen Consulting in 2006 and has been instrumental in offering thought leadership to his clients and providing services and solutions that are unique in the market.
