The Smile Test

Issac Thompson didn’t think he was doing anything wrong.




He worked as a PCP in a medical practice with a large panel of Medicare Advantage patients.




He saw all the inappropriate risk-coding requests.




The letters from the insurance company:  “We’ve reviewed your patient’s chart and determined that he has risk code XXX.XX, so we’re submitting it in your name.” (I’ve seen those letters personally about my patients, Some were as wrong as wrong can be, but there was no way for me correct them).




He saw what his insurer was doing, so he decided to take some additional direct action—and pump up his risk scores himself.




Whether via internal audits or a whistleblower looking for a piece of the action, Dr. Thompson got caught submitting false risk-codes.




And he’ll be wearing the orange jumpsuit well into the next decade.




All for doing something that CMS is concerned is being done by insurers all across the country.




The injustice must burn him every single day.




The lesson for you?




When submitting a risk diagnosis, think about how you would defend your action in front of a group of your peers.




If you can imagine doing it without smiling, you’re probably ok.




As clinicians and organizations to work to increase their financial performance, there’s a tendency to push as many risk codes as possible to CMS—sometimes inappropriately.




And CMS is concerned what was a trickle is becoming a flood.


“Use technology to extract as many risk codes from the medical record, and then push them to CMS over the prime’s signature—with or without their consent.  Any clawbacks are simply the cost of doing business”


That’s the tactic many organizations and insurers are executing.




And since everybody’s doing it, so why not just go along with it?




For one reason:  The pendulum is swinging too far.  An enforcement pushback is coming.




And it’s not the executives of the large organizations that’ll be doing the perp walks, its the clinicians in the small and medium ones.




Maybe even of the large ones.




Maybe even you.




It’s your name on the Medicare contract. It’s your name on the bottom line of each risk-code submission.  Even if you don’t financially benefit by risk-sharing it’ll be your neck in the noose.




Another reason to be concerned:  CMS can clawback revenue a full five years after collection.




They’re paying recovery auditors a percentage of recovered funds.—and the program is expanding.




Yet risk-coding rules are so complex, nobody can know them all (no, not even me).




And keeping in mind that healthcare fraud can be prosecuted even if it happens without intent, how can you be sure you’re not going to be seen as a complicit co-conspirator in the eyes of the law—how can you be sure you’re not going to be made the “fall-guy”?




The answer is simple.




The smile test.




If you’re asked to submit a code on a patient but can’t do it with a straight face, don’t.




No matter how much your administrators or coders hassle you.




No matter how much money is at stake.




Just.  Say.  No.




Somewhere in every organization, there are potential whistleblowers.




They’re slowly gathering evidence of systematic fraud hoping to cash with a piece of the action.




They know all about the smile test.




And they’re applying it to your risk-code submissions.




So you apply the smile test first, before she ever sees your coding.




Pass it, and you’ll be ok.




Fail it and if you go ahead and submit the code, you just might find yourself sharing a room with Dr. Thompson.




Orange jumpsuit and all.




And totally avoidable.






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