HealthJuly 27, 2023

Medicare advantage plans under scrutiny: Are your risk adjustment programs compliant?

With the increased scrutiny on Medicare Advantage Organizations (MAO’s) it’s now more important than ever to have a solid risk adjustment compliance program.

To quote Inspector General Christi A. Grimm at the RISE National convention in March this year, “I can tell you with great certainty that you will see us expanding our oversight of Medicare Advantage in the coming months and years. Now is truly the time to embrace the benefits of proactive, effective compliance actions and oversight.”

Compliance programs are critical in the healthcare industry to ensure that all processes are carried out in accordance with applicable laws, regulations, and ethical standards.  With the recent final ruling on RADV repayments and final announcement on payment rates for CY2024, now is the time to become laser-focused on compliance.  We have our marching orders, MA industry.   To quote Ms. Grimm again, “Private plans must make improving compliance with Medicare Advantage requirements a priority.”

So, what does a proactive and effective compliance plan look like for Medicare Advantage plans?

Five tips for building a comprehensive risk adjustment compliance plan:

1. Build a team of compliance champions

Having compliance champions that understand the rules and regulations that Medicare Advantage plans must adhere to will help inform the correct processes and policies that should be in place. Compliance officers for Medicare Advantage plans should include highly skilled, certified coders and auditors that have a deep understanding of CMS guidelines and regulatory knowledge to comply with external audits. Compliance champions play a pivotal role in ensuring the organization’s adherence to Medicare Advantage regulations and upholding the highest standards of integrity and ethics.

Questions to consider:

  • Do you have a solid compliance program in place?
  • Do you have the right people in place? 
  • Do you have the right policies and processes in place? 

2. Leverage the OIG Work Plan to identify areas of risk

OIG’s Work Plan and reports serve as a roadmap for avoiding problems. Identifying areas of risk should start with reviewing what the OIG has determined to be problematic. The OIG work plan for 2024 is here: Medicare Advantage Risk-Adjustment Data - Targeted Review of Documentation Supporting Specific Diagnosis Codes ( And past results are here: Centers for Medicare and Medicaid Services (CMS) | Office of Inspector General | U.S. Department of Health and Human Services ( Use the power of analytics within your organization to inform aberrant coding patterns. Prioritize coding projects accordingly.  If, for example, claims data shows any stroke diagnosis codes with an outpatient place of service, review these charts for accuracy as it would be exceedingly rare to have a stroke being diagnosed and treated in an outpatient setting. While this seems obvious, it is clear from the OIG reports of targeted audits of high-risk codes this coding scenario continues to be an issue.

Questions to consider:

  • Have you identified your areas of risk?
  • Have you reviewed OIG Work Plan and prior OIG report findings? 
  • Once areas of risk have been identified, have you prioritized them to mitigate risk?

3. Document policies and procedures

Develop comprehensive written policies and procedures that address all aspects of Medicare Advantage operations and compliance. Well-written compliance policies play a significant role in preventing fraud, waste, and abuse. Establish clear guidelines and procedures that help identify, prevent, and address fraudulent activities and inappropriate practices. MAOs should review and update policies regularly to keep them relevant and in line with the ever-changing regulations and best practices.

Questions to consider:

  • Have you developed and implemented policies to address areas of risk?
  • Do you have the right tools to implement these policies?
  • Do you review these policies & procedures routinely and update to remain relevant and effective?

4. Incorporate data and analytics in coder and physician training

Leveraging data and analytics from coding projects can identify areas of educational opportunities. Results should be trended for error patterns. This applies to coding errors as well as documentation deficiencies by physicians. But just identifying areas of educational opportunities isn’t enough.  The feedback loop to coders and physicians is equally as important. If they don’t understand that an error happened, how can they fix it moving forward? Because MAOs are subject to strict regulations and laws, there are also needs to be training on the consequences of non-compliance. Failure to comply with regulations can lead to legal consequences, including fines, penalties, and potential legal action.

Questions to consider:

  • Have you provided training and education to coders and physicians on compliance requirements and best practices?  
  • Have you trained and educated staff on the consequences of non-compliance?

5. Prepare for external audits with internal monitoring and audits

Internal audits such as overreading vendor results can detect issues promptly and prevent financial losses. MAOs can identify and rectify potential compliance violations before they escalate into more significant legal or financial problems. Performing overreading coding activities internally as well as vendor quality checks and mock audits will help ensure you can complete external regulatory audits successfully.

Questions to consider:

  • Do you have a system for monitoring and auditing compliance policies and procedures to ensure ongoing compliance?
  • Have you performed regular internal audits?
  • Are you prepared for external audits?

The right people, processes, and tools can enable accurate and compliant risk adjustment coding

Being compliant doesn’t mean losing money. In fact, compliance is crucial for MAOs to operate successfully and sustainably. Ensure coding projects are using 2-way coding.  2-way coding means when charts are reviewed to ensure all appropriate codes are captured as well as deleting codes that aren’t coded correctly or supported in the medical documentation.  Under coding is also a compliance issue just as over coding.  Under coding may not result in penalties, fines, and repayments, but it is an error, nonetheless.  Keeping up with all the coding and regulation changes is important so that your organization stays compliant and receives appropriate reimbursement.

Remember, compliance is a circular process because it involves continuous and iterative activities rather than a linear one-time effort. Because the Medicare Advantage landscape is quickly changing, success will be measured by the robustness and adaptiveness of your compliance framework. Being adaptive allows for quick and effective responses to regulations and industry-standard changes.

In summary, successful compliance programs sit squarely at the intersection of people, processes, and tools. A risk adjustment coding tool designed to support audit workflows can enable more accuracy and efficiency. Connect with one of our risk adjustment coding experts to discuss your current risk adjustment processes and how the Health Language Coder Workbench can help support you and your team to ensure compliance.

Explore Health Language Risk Adjustment
Melissa James, Senior Consultant, Health Language
Senior Consultant, Health Language
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