You Should Know...
A Good Week for United---A Bad One for You?
What a week for United Healthcare.
The Medicare Advantage behemoth, whose experiences in compliance enforcement is usually the best reflection of Federal policy nationwide, significantly decreased it's own compliance liabilities.
The Justice Department announced it was declining to refile an enormous qui tam action that was dismissed on October 6th. Although still under the gun for at least one other significant action, United was able to claim at least partial vindication from accusations that it systematically submitted inappropriate diagnostic risk codes for its beneficiaries.
In addition, United upped the ante on a separate compliance issue when it filed a new motion in its efforts to ask the court to throw out CMS' interpretation of the "over-payment" rule. The rule allows CMS to treat Medicare Advantage over-payments as False Claims Act violations if insurers don’t return them within 60 days of identifying them. The aim was to penalize Medicare fraud and upcoding.
United's suit, joined by more 40 other insurers, seeks to overturn this interpretation, asserting that the rule, by statute, applies only to fee-for-service Medicare payments. A verdict in their favor will further limit CMS' ability to reduce over-coding and over-payments.
What does this mean to you?
Here come the RACs.
With regulatory efforts and whistleblowing incentives limited, there will be precious few other tools left to CMS in their efforts to rein in Medicare Advantage over-payments. Expect not only significant increases in the activities of recovery audit contractors but also in the yearly CMS “over-coding" RAF adjustment released every April.
That means more documentation requests, greater risk of clawbacks and decreased gross revenue from the same level of risk coding.
Are you and your systems ready?