Gesundheit16 Februar, 2024

Preparing for a risk adjustment audit: Tips from the OIG work plan 

The Office of Inspector General (OIG) has been finding avoidable coding errors in audits. Now that they have published the 2024 work plan, do you have your response plan ready?

A primary focus of the OIG is to provide financial oversight of Medicare Advantage Organizations (MAOs). In 2022, the federal government spent more than $403 billion on managed care programs with 50 percent of the Medicare enrollees receiving care through MAOs. The Centers for Medicare & Medicaid Services (CMS) pays every MAO a monthly amount for Medicare enrollees based on their medical diagnoses in the form of a risk adjustment payment. To fight fraud, waste, and abuse and protect taxpayer dollars, the OIG conducts health plan audits as a part of its oversight of validating risk-adjusted payments made by CMS. As of August 2023, OIG audits this year had identified approximately $377 million in risk adjustment overpayments based on inaccurate coding.

Uncovering risk adjustment audit findings

In conducting the audits, OIG has identified a few consistent trends in diagnosis errors. Within the Medicare Risk-Adjustment Data-Targeted Review of Documentations Supporting Specific Diagnosis Codes audit, the watchdog targeted specific diagnosis codes utilizing specific logic. For example, Acute Stroke and Acute Heart Attack diagnoses were both pulled into an audit if there was a missing associated inpatient claim, as it is unlikely these conditions would be treated in an outpatient setting. Similarly, Major Depressive Disorder, Embolism, Vascular Claudication, Lung Cancer, Breast Cancer, Colon Cancer, and Prostate Cancer were all also audited as the diagnoses were missing associated medication or treatment claims. From non-targeted OIG compliance audits, we are seeing diagnoses such as Diabetes with Complications, Angina Pectoris, and Morbid Obesity were also either not supported, or not coded to the correct degree of severity.

Watch Now: OIG Investigations! How To Prepare Your Team

OIG work plan for future audits

OIG has no plans to slow down on the number of Medicare risk adjustment audits, in fact within the last few months it has been posting new audits as a part of its Oversight of Managed Care for Medicare and Medicaid work plan:

June 2023- Nationwide Audits of Medicare Part C High Risk Diagnosis codes. OIG will be targeting diagnoses codes that are considered high risk for being miscoded.

July 2023- Medicare Advantage Payments Generated by Health Risk Assessments for 2022OIG will be targeting diagnoses that were only reported on a Health Risk Assessment (HRA) or were added to a HRA by chart reviews. Most HRAs are in-home assessments conducted by companies hired by the MAOs, intended to identify member health status to improve patient care and health outcomes. OIG published results of a similar audit finding that an estimated $2.6 billion in risk adjustment payments from diagnosis codes were only billed on HRAs.

July 2023- CMS May Make Increased Payments to MA Organizations for Diagnoses That Were Reported on Physicians’ Claims But Were Not Confirmed on Concurrent Inpatient Stay. OIG will be focused on diagnoses found on physician or outpatient claims that did not appear on a concurrent inpatient claim.

September 2023- Audits of Medicare Part C Unlinked Chart Review Diagnosis Codes. CMS allows MA organizations to submit chart review results without identifying a date of service to CMS for inclusion in calculating each enrollee’s risk score. OIG will be focusing on whether these unlinked diagnoses are accurate.

Nine steps to prepare today for a risk adjustment audit

The final Risk Adjustment Data Validation (RADV) rule published on April 3, 2023, outlines that overpayments identified through both contract RADV and HHS-OIG audits will be extrapolated across the plan starting with PY 2018 audits. Expect recoveries from these future audits to be exponentially greater than current recovery results ($377M) that do not include extrapolation calculations.

There are multiple actions that MAOs can begin to take today to prepare for and even minimize OIG audit findings.

  1. Analyze your claims data searching for those identified high-risk diagnosis codes that were only billed once and/or that do not have related medication, procedures, or an associated inpatient stay.
  2. Seek out vendors to help you with data normalization, linking healthcare activity to claims and payments.
  3. Create a mock regulatory audit based on this analysis of data to make sure your team is prepared.
  4. Ensure that your risk adjustment coding teams support a two-way coding process of not only finding and reporting additional diagnoses, but also deleting erroneous diagnosis codes.
  5. Return any identified overpayments back to CMS within 60 days in compliance with the Federal Register / Vol. 79, No. 100.
  6. Review your HRAs and ensure that the patients are being treated for the diagnoses that are billed on these records.
  7. Increase your vendor and coder oversight by reviewing more charts for accuracy.
  8. Utilize AI-enabled risk adjustment technology, built with clinical NLP, to increase your coding efficiency and accuracy.
  9. Review your current tools and workflows to make sure you are sufficiently supported to respond to a regulatory audit. You do not want to be caught off guard without a plan.

The OIG has its work plan, do you have your response plan ready? Retrospectively reviewing for diagnosis coding errors and returning identified overpayments will prevent future negative OIG findings and extrapolated penalties. Now is the time to investigate AI-enabled technology and tools, like The Health Language Coder Workbench, to help you reduce your audit risk and ensure you can effectively respond to an OIG audit. Reach out today to speak to a risk adjustment expert and learn more.

Explore Risk Adjustment
Kimberly Rykaczewski headshot
Content Management Manager, Health Language

Kimberly Rykaczewski supports the company’s Health Language medical terminology solutions focusing on the standardization of medical terminologies to expedite data normalization to enhance healthcare system interoperability. She manages a team focused on providing data quality solutions by monitoring regulatory coding content and providing diagnostic and procedural mapping sets.

Health Language
Risk Adjustment
Enable accurate and efficient HCC risk coding for Medicare Advantage plans with an intuitive workbench that leverages AI and clinical NLP to support clinical validation.
Back To Top