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 (hhs.gov) And past results are here: Centers for Medicare and Medicaid Services (CMS) | Office of Inspector General | U.S. Department of Health and Human Services (hhs.gov). 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 the 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?