From Dr. Tom's Desk

A recent OIG study suggests that Medicare Advantage Organizations (MAOs) continue to routinely deny care to sustain their net revenue.
 
The OIG came to that conclusion based on their studies that show, upon appeal,  MAOs overturn their own care denials a supermajority of the time.
 
The OIG is also concerned that a decreasing number of denials are being submitted each year, less than 1% in 2016.
 
So, insurance companies deny care to protect their margins, knowing that only a small number of patients will bother to appeal---no surprise.
 
But that doesn’t make it a wise policy in the long run.
 
Medicare Advantage continues to generate explosive growth and until that changes there is little incentive for MAOs to address this foolish behavior.
 
What can you do?
 
Play the “good guy.”
 
Don’t be afraid of appealing adverse coverage decisions. It’ll bond your patients to you for life.
 
Remember, it’s the relationship with your patient that generates the real value in Medicare Advantage.
 
Better yet, leverage your excellent financial performance under your Medicare Advantage contract to do away with certain prior authorizations completely. That’s what we did and it was amazingly successful at boosting our performance and our patient numbers.
 
Too many organizations approach their Medicare Advantage contract with a scarcity model. Relying on care denials to give them plausible deniability with their patients on one hand while cashing their checks with the other.
 
This is exactly wrong.
 
Take great care of your patients.
 
Fight the care denials.
 
The money you spend on their services will return to you a hundred fold.

You Should Know

 
Another health care giant has been burned by a risk-coding whistleblower within their organization.
 
They settled a $270 million dollar qui tam lawsuit for over-coding without admitting wrongdoing.
 
I’ve been telling you recently that, with the invalidation of the 2014 Overpayment rule last month, it’s pretty much the Wild West as far as coding goes.
 
I also told you not to commit fraud. Don’t code for conditions that aren’t there.
 
According the government, that’s part of what this organization was accused of doing. And a coder named James Swoben is $10m richer for reporting it.
 
The inappropriate behavior was pretty blatant to the trained eye. The organization in question supposedly submitted “soft” diagnostic codes inappropriately in an inordinate number of their patients.
 
“Soft codes” are diagnostic codes with no real objective definition or measure, hard to prove, and easy to question. I talk a lot about them and how to submit them compliantly in my Success Codes blog category.
 
Spinal enthesopathy, phantom limb syndrome, sero-negative lupus.
 
These are codes which are hard to support. Their accuracy is assessed not through chart audits but through targeted statistical analysis of populations.
 
And it’s the whistleblowers in your organization that usually identify the target.
 
In this case the provider was accused of a double whammy. Not only did they supposedly collect unsubstantiated codes far in excess of what any statistical model would predict for their patient panels, but they also were accused of identifying those unsupported submissions through their internal validation audits and failing to adjust their code submissions.
 
Only their attorneys know why they settled despite the recent nullification on the 2014 Overpayment rule.  A ruling that, incidentally, leaves in place criminal penalties for fraud.
 
For you, I recommend the following:
  • Create a culture of compliance within your organization. Let the potential whistleblowers know they are welcome and rewarded for reporting variances internally rather than giving them reasons to contact an attorney. 
  • Don’t submit soft diagnoses without ample documentation that’s tailored to the patient. Incentivize your primes to get your patients in once a year to address their Success Codes and you will do very well. There’s no need to over-reach.
  • No matter how tempting, do submit ALL the data from your validation audits, even if it costs you revenue. There’s a whistleblower deep in your organization looking over your shoulder and waiting for a big payday making sure that you do. 
The OIG is increasingly questioning whether or not big settlements without admission of responsibility is an adequate deterrent to this sort of behavior. So far, I don’t know of any compliance professional having done a perp walk for this sort of wrong doing. You don’t want to be the first.
 
Why Do You Need a Medicare Advantage Mentor? Click the video to find out!

Tip From Tom


Under a Medicare Advantage contract, the sickest patients offer the greatest financial return. The effectiveness of an organization’s education and mentorship program can be judged by how thoroughly your primes have internalized this critical lesson. If your primes stop cherry picking healthy patients and start going out of their way to recruit and care for seriously ill ones, you’ll know your efforts to improve their performance have been effective.
 
It’s a great metric.
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