Notes and insights from a study published by AJMC on how to change physician behavior. “The authors evaluated methods for implementing clinical research and guidelines, in order to change physician practice patterns, in surgical and general practice. They evaluated the effectiveness of different implementation methods.”
And as we have demonstrated through successful behavior change in physicians using our HCC coding education app, the most common solutions aren’t the most effective when it comes to ongoing positive change in physician behavior. Want to learn how to change physician behavior? Let’s dig a little deeper into a review of reviews, revealing some hard truths.
We’ve been saying for years, lectures do not work. Emails do not work. If you want to know how to change physician behavior on HCC coding, don’t take our word for it. The American Journal of Managed Care released a systematic review evaluating fourteen medical reviews in an effort to understand which interventions are most effective in changing physician behavior for the better and improving patient outcomes.
It is evident from their publication that the methods of intervention most commonly deployed in teaching doctors HCC coding are rarely able to create lasting change in physician behavior.
Passive PEMs are not how to change physician behavior.
… reviews showed that formal didactic conferences and passive forms of CME, such as brochures or printed educational materials (PEMs), are the least effective methods for change and, at best, create small changes within practice. Other forms of passive dissemination, such as mailing PEMs to clinicians, were also deemed ineffective in changing physician behavior when used alone.
However, printed educational materials may be effective for raising awareness about specific behavior change. It is important to recognize that these passive approaches represent the most common approaches adopted by various healthcare organizations.
So to reiterate, the most common approach is to distribute printed materials, emails, PDFs, flyers, email blasts and the like. And this is shown to be the least effective approach.
The goal of continuing medical education (CME) for many medical professionals is to do more than raise awareness. Rather, the aim of CME is to see ongoing growth in physician performance. What methods then are most effective for creating the desired change?
Active and multifaceted methods are how to change physician behavior.
Various implementation methods are utilized to try and change physician behavior, and implementing the most effective ones is crucial to success. Our findings provide a comparison of relative effectiveness of various interventions, indicating that active forms of CME and multifaceted interventions are the most effective. In general, active approaches to changing physician performance have been shown to improve practice to a greater extent than traditional passive methods.
Active approaches … led to greater effects than traditional passive approaches. According to the findings of 3 reviews, 71% of studies included in these reviews showed positive change in physician behavior when exposed to active education methods and multifaceted interventions.
Active education methods and multifaceted interventions are the most effective when it comes to growth in physician behavior. The DoctusTech App is designed to provide active education and multifaceted interventions. In short, our app helps facilitate your desired growth as a physician. In fact, our app excels at providing the most effective methods of intervention.
…interactive education methods were identified in 3 reviews as highly effective single intervention methods for changing physician practice patterns. Interactive educational methods or active forms of CME are non didactic or lecture-based learning, focus on facilitating physician discussion, and link education experience to the physician’s clinical cases. Reminders (concurrent and automatic) were also recommended due to consistent positive results.
Deep learning is about more than gathering knowledge.
Deep learning is about more than gathering knowledge. The best way to learn is to practice and apply information. Our app allows for interactive and engaged learning by offering challenging questions in a clinical vignette to both teach and reveal gaps in knowledge while offering explanations that deepen understanding.
…learning linked to clinical practice and self-directed multifaceted active educational methods both resulted in improved physician performance.
Our study indicated that practices should focus on implementation of active methods to change physician behavior and limit use of passive dissemination of educational material or formal didactic conferences.
The DocusTech App is also multifaceted in its approach to improving physician performance! Along with engaging questions, our app incentivizes and gamifies the learning process by comparing the results within your organization in order to determine where you organization lands externally with all users. The challenging questions and incentivizing nature of our app is designed to promote deep engagement through ongoing discussion and learning among physicians.
…multifaceted interventions were most effective in changing physician practice patterns. Multifaceted interventions included a combination of active interventions: audit and feedback, reminders, local consensus or marketing, academic outreach, and interactive education.
The DoctusTech app knows that Active and Multifaceted methods are how to change physician behavior.
The DoctusTech App utilizes the same methods that have proven to help improve physician behavior. And just to reiterate, this is not a zoom call, a classroom style lecture, an email blast, or printed flyers. There are proven to be far less impactful or effective. Our app utilizes the most advanced intervention methods with the aim of replacing boring and ineffective lecture-style learning with engaging, challenging, and on-demand learning through questions that test your knowledge while filling-in knowledge gaps.
…multifaceted interventions and active forms of CME were rated the most effective implementation methods to change physician behavior for a desired outcome.
Are you struggling with how to change physician behavior?
See how the DoctusTech app is changing physician behavior right now! Using multifaceted and deeply engaging interventions, educating physicians on HCC coding has never been more effective and efficient.
Schedule a conversation with Dr. Kazi today, and start to see change physician knowledge, behavior and accuracy in HCC coding today!.
Medicare Advantage Compliance Audits: The Department of Health and Human Services Office of Inspector General regularly audits Medicare Advantage contracts and reports out specific diagnosis codes deemed improper. They also report the estimated overpayments associated with the specific diagnosis codes, and recommend repayments. Below, you’ll find all of the specific “High Risk HCC codes” targeted in these recent HHS OIC Medicare Advantage compliance audits.
High Risk HCC codes targeted in 5 recent HHS OIC Medicare Advantage compliance audits:
And the organizations associated with misuse
Acute stroke: An enrollee received an acute stroke diagnosis (which maps to the HCC entitled Ischemic or Unspecified Stroke) on one or two physician claims during the service year but did not have that diagnosis on a corresponding inpatient hospital claim. A diagnosis of history of stroke (which indicates that the provider is evaluating or treating residual conditions left behind by a prior stroke and which does not map to an HCC) typically should have been used. Anthem, Coventry, Healthfirst, Tufts, UPMC
Major depressive disorder: An enrollee received a major depressive disorder diagnosis (which maps to the HCC entitled Major Depressive, Bipolar, and Paranoid Disorders) on one or two claims during the service year, rather than on several claims, which would have reflected long-term treatment. It is possible that a diagnosis of a less severe form of depression (which does not map to an HCC) should have been used. Anthem, Coventry, Healthfirst, Tufts, UPMC
Acute heart attack: An enrollee received one diagnosis that mapped to either the HCC for Acute Myocardial Infarction or to the HCC for Unstable Angina and Other Acute Ischemic Heart Disease (Acute Heart Attack HCCs) on only one physician claim but did not have that diagnosis on a corresponding inpatient hospital claim (either within 60 days before or 60 days after the physician’s claim). A diagnosis for a less severe manifestation of a disease in the related-disease group typically should have been used. Anthem, Coventry, Tufts, UPMC
Acute stroke and acute heart attack combination: An enrollee met the conditions of both the acute stroke and acute heart attack high-risk groups in the same year. Anthem, Coventry, Healthfirst, Tufts, UPMC
Embolism: An enrollee received one diagnosis that mapped to either the HCC for Vascular Disease or to the HCC for Vascular Disease With Complications (Embolism HCCs) but did not have an anticoagulant medication dispensed on his or her behalf. An anti-coagulant medication is typically used to treat an embolism. A diagnosis of history of embolism (an indication that the provider is evaluating a prior acute embolism diagnosis, which does not map to an HCC) typically should have been used. Anthem, Coventry, Healthfirst, Tufts, UPMC
Incorrectly Submitted Diagnosis Codes for Breast Cancer: UPMC Incorrectly Submitted Diagnosis Codes for Colon Cancer : , UPMC Incorrectly Submitted Diagnosis Codes for Lung Cancer: , UPMC
Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services (CMS) makes monthly payments to MA organizations according to a system of risk adjustment that depends on the health status of each enrollee. Accordingly, MA organizations are paid more for providing benefits to enrollees with diagnoses associated with more intensive use of health care resources than to healthier enrollees, who would be expected to require fewer health care resources.
To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS. Some diagnoses are at higher risk for being miscoded, which may result in overpayments from CMS.
In the past few months, a large number of these audits have been released. Here are the summaries of just a few.
HHS OIC Medicare Advantage compliance audit #1
Humana, Inc. – $197.7 Million
How OIG Did This Audit
For this audit, we reviewed one of the contracts that Humana, Inc., has with CMS with respect to the diagnosis codes that Humana submitted to CMS. Our objective was to determine whether Humana submitted diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements.
We selected a sample of 200 enrollees with at least 1 diagnosis code that mapped to an HCC for 2015. Humana provided medical records as support for 1,525 HCCs associated with the 200 enrollees. We used an independent medical review contractor to determine whether the diagnosis codes complied with Federal requirements.
Humana Did Not Submit Some Diagnosis Codes in Accordance With Federal Requirements
Some of the Diagnosis Codes That Humana Submitted to CMS
Were Not Supported in the Medical Records
Diagnosis Codes That Humana Should Have Submitted but Did Not
Submit to CMS
What OIG Found
Humana did not submit some diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements. First, although most of the diagnosis codes that Humana submitted were supported in the medical records and therefore validated 1,322 of the 1,525 sampled enrollees’ HCCs, the remaining 203 HCCs were not validated and resulted in overpayments. These 203 unvalidated HCCs included 20 HCCs for which we identified 22 other, replacement HCCs for more and less severe manifestations of the diseases. Second, there were an additional 15 HCCs for which the medical records supported diagnosis codes that Humana should have submitted to CMS but did not.
Thus, the risk scores for the 200 sampled enrollees should not have been based on the 1,525 HCCs. Rather, the risk scores should have been based on 1,359 HCCs (1,322 validated HCCs + 22 other HCCs + 15 additional HCCs). As a result, we estimated that Humana received at least $197.7 million in net overpayments for 2015. These errors occurred because Humana’s policies and procedures to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective.
What OIG Recommends and Humana’s Comments
We recommend that Humana refund to the Federal Government the $197.7 million of net overpayments and enhance its policies and procedures to prevent, detect, and correct noncompliance with Federal requirements for diagnosis codes that are used to calculate risk-adjusted payments.
Humana disagreed with our findings and with both of our recommendations. Humana provided additional medical record documentation which, Humana said, substantiated specific HCCs. Humana also questioned our audit and statistical sampling methodologies and said that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program. After reviewing Humana’s comments and the additional information that it provided, we revised the number of unvalidated HCCs for this final report. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program. We revised the amount in our first recommendation from $263.1 million (in our draft report) to $197.7 million but made no change to our second recommendation.
For this audit, we reviewed one MA organization, UPMC Health Plan, Inc. (UPMC), and focused on 10 groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that UPMC submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.
We sampled 280 unique enrollee-years with the high-risk diagnosis codes for which UPMC received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $975,223.
Most of the Selected High-Risk Diagnosis Codes That UPMC Submitted to CMS Did Not Comply With Federal Requirements
Incorrectly Submitted Diagnosis Codes for Acute Stroke
Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
Incorrectly Submitted Diagnosis Codes for Acute Stroke and Acute Heart Attack Combination
Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
Incorrectly Submitted Diagnosis Codes for Embolism
Incorrectly Submitted Diagnosis Codes for Vascular Claudication
Incorrectly Submitted Diagnosis Codes for Lung Cancer
Incorrectly Submitted Diagnosis Codes for Breast Cancer
Incorrectly Submitted Diagnosis Codes for Colon Cancer
Potentially Mis-keyed Diagnosis Codes
What OIG Found
With respect to the 10 high-risk groups covered by our audit, most of the selected diagnosis codes that UPMC submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 194 of the 280 enrollee-years, the diagnosis codes that UPMC submitted to CMS were not supported in the medical records and resulted in $681,099 of net overpayments for the 194 enrollee-years.
These errors occurred because the policies and procedures that UPMC had to ensure compliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. On the basis of our sample results, we estimated that UPMC received at least $6.4 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.
What OIG Recommends and UPMC Comments
We recommend that UPMC refund to the Federal Government the $6.4 million of estimated net overpayments; identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and continue its examination of existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS’s risk adjustment program) and take the necessary steps to enhance those procedures.
UPMC disagreed with our findings and recommendations. UPMC provided additional information which, according to UPMC, validated HCCs for 25 sampled enrollee-years. UPMC questioned both our audit methodology and the qualifications of our independent medical review contractor. UPMC also stated that we did not calculate overpayments according to CMS requirements and that it disagreed with our extrapolation methodology and our assessment of its compliance program. After reviewing UPMC’s comments and the additional information that it provided, we revised the number of enrollee-years in error for this final report. We followed a reasonable audit methodology, used a qualified medical review contractor, correctly applied applicable Federal requirements underlying the MA program, and properly assessed UPMC’s compliance program. We revised the amount in our first recommendation from $6.6 million (in our draft report) to $6.4 million but made no change to our other recommendations.
We sampled 240 unique enrollee-years with the high-risk diagnosis codes for which Healthfirst received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $787,928.
Most of the Selected High-Risk Diagnosis Codes That Healthfirst Submitted to CMS Did Not Comply With Federal Requirements
Incorrectly Submitted Diagnosis Codes for Acute Stroke
Incorrectly Submitted Diagnosis Codes for Acute Stroke and Acute Heart Attack Combination
Incorrectly Submitted Diagnosis Codes for Embolism
Incorrectly Submitted Diagnosis Codes for Vascular Claudication
Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
Potentially Mis-keyed Diagnosis Codes
What OIG Found
With respect to the seven high-risk groups covered by our audit, most of the selected diagnosis codes that Healthfirst submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 155 of the 240 enrollee-years, the diagnosis codes that Healthfirst submitted to CMS were not supported in the medical records and resulted in net overpayments of $516,509.
These errors occurred because the policies and procedures that Healthfirst had to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. On the basis of our sample results, we estimated that Healthfirst received at least $5.2 million in net overpayments for these high-risk diagnosis codes in 2015 and 2016.
What OIG Recommends and Healthfirst Comments
We made a series of recommendations to Healthfirst, including that it: refund to the Federal Government the $5.2 million of net overpayments; identify, for the diagnosis codes described in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and continue its examination of existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes that are at high risk for being miscoded comply with Federal requirements and take the necessary steps to enhance those procedures.
Healthfirst objected to all of our recommendations; however, it did not object to any of the errors we identified. Instead, Healthfirst requested we limit our recommended recovery to the overpayments identified in our sample-not the extrapolated value of those overpayments. Healthfirst stated that OIG lacked the authority to use extrapolation to recommend a repayment and disagreed with our extrapolation methodology. It also stated that our audit methodology did not account for a payment principle known as “actuarial equivalence” and disagreed that it should perform audits of high-risk diagnoses or enhance its compliance program. After reviewing Healthfirst’s comments, we maintain that our findings and recommendations are valid. No statutory authority limits our use of extrapolation to estimate a recovery and we correctly applied Federal requirements underlying the MA program.
For this audit, we reviewed one MA organization, Tufts Health Plan, Inc. (Tufts), and focused on seven groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Tufts submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.
We sampled 212 unique enrollee-years with the high-risk diagnosis codes for which Tufts received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $746,427.
Most of the Selected High-Risk Diagnosis Codes That Tufts Health Plan Submitted to CMS Did Not Comply With Federal Requirements
Incorrectly Submitted Diagnosis Codes for Acute Stroke
Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
Incorrectly Submitted Diagnosis Codes for Acute Stroke and Acute Heart Attack Combination
Incorrectly Submitted Diagnosis Codes for Embolism
Incorrectly Submitted Diagnosis Codes for Vascular Claudication
Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
Potentially Mis-keyed Diagnosis Codes
What OIG Found
Most of the selected diagnosis codes that Tufts submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 58 of the 212 sampled enrollee-years, the medical records validated the reviewed Hierarchical Condition Categories (HCCs). However, for the remaining 154 enrollee-years, the diagnosis codes were not supported in the medical records. These errors occurred because the policies and procedures that Tufts had to ensure compliance with CMS’s program requirements, as mandated by Federal regulations, could be improved. As a result, the HCCs for some of the high-risk diagnosis codes were not validated. On the basis of our sample results, we estimated that Tufts received at least $3.7 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.
What OIG Recommends
We recommend that Tufts: (1) refund to the Federal Government the $3.7 million of net overpayments; (2) identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and (3) continue to improve its existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS’s risk adjustment program) and take the necessary steps to enhance those procedures.
Tufts did not concur with our findings and recommendations. Tufts stated that we should not have included the errors associated with 5 enrollee-years in our calculation of total net overpayments because, according to Tufts, it had already submitted corrections to CMS. Tufts did not specifically comment on the errors associated with the other 154 enrollee-years. Tufts disagreed with our sampling and review methodologies, and stated that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program.
After consideration of Tufts’ comments, we maintain that our findings and recommendations are valid. However, we revised our findings for the 5 enrollee-years and considered the impact of the budget sequestration reduction; therefore, we reduced our first recommendation from $4,013,034 to $3,758,335 for our final report. We also revised the beginning of our third recommendation in recognition of Tuft’s past efforts to improve its compliance program.
Anthem Community Insurance Company, Inc. – $3.47 million
How OIG Did This Audit
For this audit, we reviewed one MA organization, Anthem Community Insurance Company, Inc. (Anthem), and focused on seven groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Anthem submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.
We sampled 203 unique enrollee-years with the high-risk diagnosis codes for which Anthem received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $599,842.
Most of the Selected High-Risk Diagnosis Codes That Anthem Submitted to CMS Did Not Comply With Federal Requirements
Incorrectly Submitted Diagnosis Codes for Acute Stroke
Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
Incorrectly Submitted Diagnosis Codes for Acute Stroke and
Acute Heart Attack Combination
Incorrectly Submitted Diagnosis Codes for Embolism
Incorrectly Submitted Diagnosis Codes for Vascular Claudication
Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
Potentially Mis-keyed Diagnosis Codes
What OIG Found
With respect to the seven high-risk groups covered by our audit, most of the selected diagnosis codes that Anthem submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 123 of the 203 enrollee-years, the diagnosis codes that Anthem submitted to CMS were not supported in the medical records and resulted in $354,016 of net overpayments for the 203 enrollee-years.
These errors occurred because the policies and procedures that Anthem had to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. On the basis of our sample results, we estimated that Anthem received at least $3.47 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.
What OIG Recommends and Anthem Comments
We recommend that Anthem refund to the Federal Government the $3.47 million of net overpayments; identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and enhance its compliance procedures to focus on diagnosis codes that are at high risk for being miscoded by (1) determining whether these diagnosis codes (when submitted to CMS for use in CMS’s risk adjustment program) comply with Federal requirements and (2) educating its providers about the proper use of these diagnosis codes.
Anthem did not concur with our findings and recommendations. Anthem disagreed with our findings for 2 specific enrollee-years and provided additional explanations. Anthem also did not agree with the methodologies that we used to review the selected diagnoses and to calculate the $3.47 million of net overpayments. Anthem also said that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program.
After reviewing Anthem’s comments and the information provided, we maintain that all of our findings and recommendations remain valid. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program.
For this audit, we reviewed one MA organization, Coventry Health Care of Missouri, Inc. (Coventry), and focused on six groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Coventry submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.
We judgmentally selected 275 unique enrollee-years with the high-risk diagnosis codes for which Coventry received higher payments for 2014 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $701,593.
Most of the Selected High-Risk Diagnosis Codes That Coventry Submitted to CMS Did Not Comply With Federal Requirements
Incorrectly Submitted Diagnosis Codes for Acute Stroke
Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
Incorrectly Submitted Diagnosis Codes for Embolism
Incorrectly Submitted Diagnosis Codes for Vascular Claudication
Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
Potentially Mis-keyed Diagnosis Codes
What OIG Found
Most of the selected diagnosis codes that Coventry submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 226 of the 275 enrollee-years, the diagnosis codes that Coventry submitted to CMS were not supported in the medical records.
These errors occurred because the policies and procedures that Coventry had to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. As a result, Coventry received $548,852 of net overpayments for 2014 through 2016.
What OIG Recommends and Coventry’s Comments
We recommend that Coventry refund to the Federal Government the $548,852 of net overpayments; identify, for the diagnoses included in this report, similar instances of noncompliance that occurred during our audit period that we did not review and outside of our audit period and refund any resulting overpayments to the Federal Government; and enhance its compliance procedures to focus on diagnosis codes that are at high risk for being miscoded by: (1) educating its providers about the proper use and documentation of these diagnoses and (2) determining whether these diagnosis codes (when submitted to CMS for use in CMS’s risk adjustment program) comply with Federal requirements.
Coventry agreed that most of the reviewed diagnosis codes were not supported by medical records and said that it had identified $542,541 to refund to the Federal Government. However, Coventry did not agree with the other findings associated with our first recommendation and submitted additional documentation for our consideration. Coventry did not agree with our other recommendations and said that our report contained a number of serious flaws that fundamentally undermined our audit methodology, findings, and recommendations. Coventry also stated that it had made enhancements to its compliance processes since our audit period, including provider education.
After reviewing Coventry’s comments and the additional documentation that it provided, we revised the number of enrollee-years in error. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program. We revised the recommendation to refund overpayments from $584,005 (in our draft report) to $548,852 and slightly revised some of the language in our third recommendation.
Excerpts, notes and quotes from the DOJ 2021 Fiscal Year Report
The DOJ DOJ Healthcare Audits Charged $5 Billion In 2021, according to a recent report. The Department of Justice released an analysis of all False Claims Act settlements and judgments in fiscal year 2021, revealing $5 Billion against healthcare, out of a $5.6B total. Healthcare represented 89% of all DOJ FCA judgments and settlements for the year.
The False Claims Act is the government’s primary civil tool to redress false claims involving other government operations and functions.
“The Justice Department obtained more than $5.6 billion in settlements and judgments from civil cases involving fraud and false claims against the government in the fiscal year ending Sept. 30, 2021”
— Acting Assistant Attorney General Brian M. Boynton of the DOJ’s Civil Division
In the False Claims Act history, this is the second largest annual total, and the largest since 2014. Settlement and judgments now total north of $70 billion since 1986, when Congress substantially strengthened the civil False Claims Act by boosting incentives up to 30% for whistleblowers. In 2021, whistleblowers filed 598 qui tam suits.
DOJ Healthcare Audits account for nearly 90% of all DOJ charges
Of the more than $5.6 billion in settlements and judgments reported by the Department of Justice this past fiscal year, over $5 billion relates to matters that involved the healthcare industry, including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories and physicians. The amounts included in the $5 billion reflect recoveries arising from only federal losses, and, in many of these cases, the department was instrumental in recovering additional amounts for state Medicaid programs.
“Ensuring that citizens’ tax dollars are protected from fraud and abuse is among the department’s top priorities… The False Claims Act is one of the most important tools available to the department both to deter and to hold accountable those who seek to misuse public funds.”
— Acting Assistant Attorney General Brian M. Boynton of the DOJ’s Civil Division
First Place: Health Care Fraud
Healthcare fraud was once again in the lead as the top source of the department’s False Claims Act settlements and judgments. The department’s efforts restore funds to federal programs such as Medicare, Medicaid and TRICARE and prevent billions in losses by acting as a deterrent. Often, also protecting patients from medically unnecessary or potentially harmful actions.
Second Place: Medicare Advantage
Prosecuting Plans AND Providers for Over-Coding, Up-Coding
In 2021, more than 26 million Medicare beneficiaries were enrolled in Medicare Advantage plans, and the Congressional Budget Office projected that CMS would pay more than $343 billion for those plans.
The department has pursued plans and healthcare providers that manipulated the risk adjustment process by submitting unsupported diagnosis codes to make their patients appear sicker than they actually were. This year, Sutter Health, a California-based health care services provider, paid $90 million to resolve allegations that it knowingly submitted unsupported diagnosis codes for certain patient encounters, resulting in inflated payments to be made to the Medicare Advantage Plans and Sutter Health. In addition, Kaiser Foundation Health Plan of Washington, formerly known as Group Health Cooperative (GHC), paid $6.3 million to resolve allegations that it submitted invalid diagnoses and received inflated payments as a result. In addition, the department intervened and filed complaints in separate lawsuits against Independent Health Corporation and members of the Kaiser Permanente consortium alleging that those Medicare Advantage organizations submitted or caused the submission of inaccurate information about the health status of beneficiaries enrolled in their plans to increase reimbursement from Medicare.
Humana’s Chief Medical Officer, William Shrank, MD, MSHS, co-wrote a study in March (published by JAMA) titled “Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries.” (Gondi S, Li Y, Drzayich Antol D, Boudreau E, Shrank WH, Powers BW. Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries. JAMA Netw Open. 2022;5(3):e222916. doi:10.1001/jamanetworkopen.2022.2916)
It is a very quick read, but here’s the highlight reel:
Downside Risk vs. Fee For Service
“Compared with FFS, beneficiaries cared for under 2-sided risk models had lower rates of hospitalizations, observation stays, and ED visits.”
“Compared with FFS, 2-sided risk models were associated with a 15.6% (95% CI, 14.2%-17.0%) relative reduction in avoidable hospitalizations, compared with 4.2% (3.4%-4.9%) for all-cause hospitalizations (Figure).”
Upside Risk vs. Fee For Service
“For all outcomes, there was no significant difference in acute care use between beneficiaries cared for under upside-only risk models and FFS.”
Further Discussion
“In this study of MA beneficiaries, advanced value-based payment arrangements (ie, 2-sided risk models) were associated with lower rates of acute care use, especially those events that are potentially avoidable. These findings are consistent with evaluations of value-based payment in traditional Medicare and serve to expand the evidence base around value-based payment models in Medicare Advantage.1 The lack of significant differences between FFS and upside-only risk models suggests that downside financial risk may play a key role in effective value-based payment arrangements.”
This study had limitations.
Stephen Kemble, MD (Queen’s Medical Center, Honolulu) and Gordon Moore, MD, MPH (Professor of Population Medicine, Harvard Medical School, Boston, MA) both brought up valid concerns in the comments section, calling out the potential for selection bias, and even asserting that the study does not answer the question it purports to address.
Obviously, there is more to learn. But what do you think? Is the data telling you that downside risk decreases avoidable hospitalizations? Or is something else at play? And if so, what do you think it is?
A guest walks into an upscale hotel and unburdens himself of several suitcases into the waiting hands of an eager bellhop. When both arrive at the room, rather than giving a tip, the guest offers a hearty thanks! With a dry smile, the bellhop frankly states, “‘Thank you’ don’t feed the bulldog.”
And he’s right. For all the talk of improving outcomes and reducing costs, it takes money to provide the kind of care that truly improves outcomes. But in the same breath, caring for the health of a population is very clearly not about the money. So how does a $4+ TRILLION-with-a-T industry improve outcomes and reduce costs while balancing on the razor-thin line that both is and is not about the money?
In the Value-Based Care space, the full risk model is often called the “silver bullet,” AKA the only thing going that is trending toward a sustainable solution. Full risk is, in fact, all about the money: how it is deployed, where it is directed, and what mechanisms are in place to either gain or lose the money.
(But also, it’s not about the money.)
Provider groups are not jumping ship from their traditional fee-for-service model into full risk because each clinician in the group finds herself in need of a new boat. The transition from FFS to VBC is driven by that same spark that drew optimistic kids out of college and into medical school: the desire to help people.
And nothing helps people stay healthy like a full risk model, or as it’s known in some corners of the world, “Mutual Assured Destruction.”
The HCPLAN’s annual report (Health Care Payment Learning & Action Network) shows a slow but consistent rise in dollars spent in VBC arrangements, and a glacially slow (but steady!) decline in dollars spent in FFS arrangements.
The proof is in the pudding. And the pudding is made out of data. Humana’s Chief Medical Officer, William Shrank, MD, MSHS, co-wrote a study in March that seeks to answer the correlation between avoidable hospital visits and models of payment and risk. Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries(Gondi S, Li Y, Drzayich Antol D, Boudreau E, Shrank WH, Powers BW. Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries. JAMA Netw Open. 2022;5(3):e222916. doi:10.1001/jamanetworkopen.2022.2916).
In that piece, we see the smoking gun that fired the silver bullet that is gradually improving outcomes and reducing costs:
Compared with FFS, beneficiaries cared for under 2-sided risk models had lower rates of hospitalizations, observation stays, and ED visits. For example, the adjusted rate of ED visits per 1000 patients for 2-sided risk models was 375.8 (95% CI, 370.9-380.7) compared with 434.1 (95% CI, 426.5-441.9) for FFS. For all outcomes, there was no significant difference in acute care use between beneficiaries cared for under upside-only risk models and FFS.
The association between value-based payment and decreased acute care use was most pronounced for measures of avoidable acute care use. Compared with FFS, 2-sided risk models were associated with a 15.6% (95% CI, 14.2%-17.0%) relative reduction in avoidable hospitalizations, compared with 4.2% (3.4%-4.9%) for all-cause hospitalizations
So in a fair fight, when it comes to reducing avoidable hospitalizations, full risk—or 2-sided risk, downside risk—beats both FFS AND shared savings by a healthy margin.
You have probably heard the phrase “the fear of pain is a greater motivator than the desire for pleasure.” Freud, Maslow, and even Psychology Today speak to this, but very few examples illustrate the principle so vividly as when comparing upside risk or “shared savings” (a reward) against 2-sided risk models (full risk, AKA the opportunity to lose money).
This is also known as “aligning incentives.” Simply put, if Jerry stays healthy, Jerry’s doctor keeps more money, but if Jerry takes a costly trip to the ED (Expensive Department), his full-risk-bearing healthcare provider pays the piper.
While Jerry may be motivated to keep his diabetes under control and stick with his medication, his provider is financially incentivized to do all of the things that reduce those avoidable hospitalizations.
Beyond the annual wellness visit, there are myriad things that are shown to reduce those acute events. Send Jerry home with a remote patient monitoring device and assign staff to monitor the results. Call Jerry to ensure he’s doing okay. Ensure he has transportation to and from the clinic. Offer other services in clinic to make Jerry want to come for a visit. (Looking at you, Florida, with the haircuts, mani-pedis, fresh produce, mental health counseling, and full-time massage therapist, all at no cost to Jerry.)
Obviously, in the relationship between money and healthcare, it’s complicated…. But by shifting risk in the direction of providers, the data show that avoidable hospitalizations are less and outcomes are improving, which directly impacts cost of care.
We recently ran a poll asking how doctors preferred to learn about HCC documentation training tools and resources, and 50% selected “Peer Recommendations.” Fortunately, doctors just like you are using and loving our platform, and eager to share their experiences. We’ve broken their testimonials into three categories: Ease of use, Depth of learning, Accuracy, and Quality of education.
“There are a lot of other programs out there, but not like this.” – Dr. Jose a Villaplana-Canals, MD
“Providers are not going to be able to do this much longer without tools. Even the Cadillac of EMRs has its limitations, and you’re never going to get away from provider education; it’s necessary.” – Teresa Caniglia, CDI
1. The format is easy and convenient to use
HHC coding education right on your phone makes it easy to learn, anytime, any place. Unlike lectures or even one-on-one coaching, the simplicity and convenience of the app allow you to engage in ongoing training throughout the day. Although, it only takes about 5 minutes per week to stay up to date!
It’s an easy format to follow. The mobile app is really easy to use and launch. It’s nice just having it with you rather than trying to read an article or listen to a podcast. . – Dr. Joseph Bateman
The mobile app is wonderful in that it’s a clinical vignette – it’s what is literally in front of their face, and it gets them thinking. – Teresa Caniglia, CDI
It’s nice. You know, I’ll be sitting down to eat something, or I’ll be sitting in a waiting room somewhere waiting to go to my doctor, physical therapy, whatever. Then I’ll just pull the app up, and I’ll do, you know, five or ten questions, click and shut it down, and you go do your thing. – Dr. Joseph Bateman
The app seems easy to use. – Dr. Jeffrey Linder
2. Clinical Vignettes increase memory and insights
Deep learning isn’t just about getting the information, it is about knowing what to do with that information. The DoctusTech App helps you learn through challenging questions that reveal gaps in knowledge and explanations that deepen understanding.
I like the concise feedback you get when you get a question wrong. And it tracks your progress. Looking at the right answer and why it’s the right answer – that’s very, very helpful. – Dr. Joseph Bateman
And yes, you miss questions, but that’s how you learn. And you can read afterward the rationale for the answers, and you learn right there. – Dr. Jose a Villaplana-Canals, MD
Our app also incentivizes ongoing learning by gamifying the process of growing in your knowledge of HCC coding. You can compare results within your organization and determine where your organization lands externally with all users.
I like to be challenged, and that’s the way I learn – because it makes you remember. – Dr. Jose a Villaplana-Canals, MD
It’s concise, challenging, and when you find yourself between 2 answers, it’s challenging and makes you think! – Dr. Jose a Villaplana-Canals, MD
The app also helps with knowledge retention in ways that are impossible with lectures and books alone.
And I also liked the fact that the information key principles are continuously repeated and asked in a different way. So you really get to know the concept. And it becomes more intuitive for you when you’re working on a patient’s chart. – Dr. Joseph Bateman
When you’re seeing patients, you remember the questions, and you remember what you need to ask the patients. – Dr. Jose a Villaplana-Canals, MD
This highlights your knowledge and what you do or don’t know. The detailed answers help me to understand why it’s the right answer – Dr. Cynthia Ambler
3. The information is current and up-to-date
You need current, relevant and up-to-date information. The best way to stay up to date on all the changes in HHC coding is by regularly engaging with the Doctus Tech App.
You’re never going to be able to teach them everything they need to know in 60-90 minutes. This is never going to be a one-and-done. Medicine is broad, and it’s changing and developing. – Teresa Caniglia, CDI
It is definitely up to date. Any educational program helps physicians prep for boards, so this is a board question format. And that helps. – Dr. Jose a Villaplana-Canals, MD
As the body of knowledge grows, surely the use of digital tools is going to become pretty normal. – Dr. Joseph Bateman
I learned so many interesting things that I didn’t know I should look for. – Dr. Vljayalakshml Thota
4. The format is designed for learning
The DoctusTech App is designed to help you navigate the complex and changing world of HHC coding. The aim of our app is to replace boring lecture-style learning with engaging, challenging, and on-demand learning through questions that test your knowledge while filling-in knowledge gaps.
Question prompts are long, but I learned a lot. – Dr. Laura Tagle
It’s changing the way I’m thinking and how I’m going to document. I wasn’t consistent before this training. It’s an essential self-improvement exercise. – Dr. Patrick Towne
Content looks like my patient population. I’m trying to apply what I learned to my documentation now because it directly relates to my patient care. – Dr. Steven Lobue
Those of us in the know and leadership understand the importance of this and how it’s going to play an increasing role in our ability to deliver, to get paid, to deliver complex care. I personally understand how important it is to have someone use this versus another form of learning. I feel is that this is more intuitive and is full of kind of “aha” moments. All of my other education on this topic hasn’t really been that iterative or intuitive. I think this is the best thing I’ve come across to teach us some of the basic tenants. I got more out of it than I anticipated. I think you underpromised and over-delivered. – Dr. Joseph Bateman
Live with Dr. Kazi is a new video series from Value-Based Care expert, Farshid Kazi, MD – Co-founder of DoctusTech, and passionate advocate for HCC coding and the Quadruple Aim. In our third episode, Dr. Kazi shares ways in which HCC coding is good for the country.
Watch the full interview here!
I’m Farshid Kazi, co-founder of DoctusTech and an internist by training with a focus on palliative care.
I’ve built my career on population health out in California.
I’m excited to help other physicians looking to take the journey and leap into value-based care.
Levi Wiggins: On another episode of Live with Dr. Kazi! You are a population health expert & co-founder of DoctusTech. And today we’re going to do a bit of a deep dive into the recent case of the Department of Justice and whistleblower Cathy Ormsby against Sutter Health and Affiliates, with their false claims act violations, alleged, and the $90 Million settlement.
What is the first thing you think when you hear about that case?
Farshid Kazi MD: It makes me sad. I mean, I think a lot of us providers know that there’s a lot of pressure around documentation accuracy, and it felt like it was a Swiss-cheese effect. I have to think that my colleagues in the field of value-based care are trying to do everything right.
Always trying to be accurate and document appropriately. But sometimes, when you set up systems in piecemeal, there’s not a proper safety net to catch when multiple errors happen, the perfect way. And unfortunately, that was what the situation looks like it could have been at Sutter Health.
Levi Wiggins: I mean, in the, the big 45 page piece that the DOJ released, there were a lot of different parts that got highlighted. And I think we were discussing earlier some of the things that they did make perfect sense, like that’s a good idea, right?
Farshid Kazi MD: Yeah. That’s right. You want to bring in your patients once a year, talk about the medical conditions, talk about what’s happening, make sure that everything’s safe at home.
Really try to plan ahead for the following year. So the concept around an annual wellness visit. Completely kosher. It’s actually encouraged and something that us providers look forward to doing. And oftentimes during those visits, you will document HCC diagnoses. These are things that the patients have.
You want to talk about it with the patients. Tell the plans, tell the Medicare, talk about what their medical conditions are, and also think about what you’re going to do preventatively for that following year. And during that visit, you’ll often document HCC diagnoses, and sometimes programs will provide providers with all the information possible so they can properly document during that visit.
But what you want to do is be careful that you’re not helping increase the up documentation or up-coding and making sure on the backend, everything is compliant. And sometimes if you’re just focusing on the documentation, and making sure the diagnoses are in the chart before claims is submitted and not thinking about the compliance piece, that’s kind of where you can end up in Sutter’s situation.
Levi Wiggins: Now, I read that they set a goal to increase their risk adjustment scores by 28%.It seems a little high.
Farshid Kazi MD: Yeah, nationally, the average is around 3%. When you think about risk adjustment going up every year. And so typically, we never try to tell providers, “we have a target on which we want to increase the RAF.”
It’s more about how do we improve our accuracy. So thinking about both up and down. So if you’re having diagnoses that you’re carrying over that are inaccurate, really trying to empower your providers to say, “Hey, this should not be submitted.” Or “this is inaccurate,” is the right way to think about it.
So, setting a goal of 28%, again, not having been in their shoes. Perhaps it was more around increasing their accuracy and not necessarily increasing the score, which would be a no-no.
Levi Wiggins: And how do you feel about a coder coming in after the encounter and adding a few codes that the clinician may have just simply overlooked.
Farshid Kazi MD: You know, what Sutter had in place is no different than multiple groups across the United States. They have work being done before the patient visit, they have worked being done after the patient visit; coders are an integral part of the team to accurately reflect the work that providers are doing with patients.
And the problem comes when you’re suggesting diagnoses to providers who have not necessarily been educated around why that’s being presented in front of them and given them a workflow that allows them to only check boxes to carry diagnosis over so they can get through the workday.
The key really here is, are you giving the right information, educating the providers and allowing them to make a clinical decision? So when you have a coder coming in and suggesting something that wasn’t necessarily documented at the point of care, it becomes a little bit more of a gray area. And you want to be very clear that your provider understands why they’re being suggested that diagnosis.
And then given the power to say yes or no one, either direction.
Levi Wiggins: We talk about a lot of risk adjustment, but the risk to providers that this case seems to indicate is that not just CMS, but also the DOJ is very concerned – this is the first time I’ve seen the, the word mischarging. Talk about the risk to provider groups, now.
Farshid Kazi MD: Yeah. I mean, this is a whistleblower case, right? So we know that the reason that the DOJ looked at this was because someone raised their arms and said, “Hey, this doesn’t feel right.” RADV audits are another way to prevent abuse of the Medicare advantage documentation compliance programs.
But that right now is focused just on payors. Every time we talk to provider groups, or I speak with a colleague, I’m always trying to encourage them to think about compliance more than RAF accuracy, because it’s only a matter of time with the Direct Medicare Contracting model. ACOs taking downside risk that provider groups who are taking on this risk are going to be held accountable in the same way that a payor is.
And so it’s unfair for us to say, look, we submitted a clinical diagnosis without justification. It’s up the plan to figure out whether we are compliant or not. And then we’re shielded by the plan. So right now, all audits through MA plans are happening at the payor level. But I’m really confident it’s only a matter of time before it starts coming back to us provider groups.
So this, if nothing else, should make people a little nervous, or do they have the right processes in place? Are you educating your providers to understand the “why” around risk adjustment? Am I accurately documenting? Do I have the right justification? And am I given the right amount of time to say yes or no to these diagnoses?
If you don’t have the right information, you should not be carrying over any diagnosis. That is just a yes, because it’s going to make your boss happy or make you get through the day easier. So making sure that conversation is happening is integral to making sure that the next piece- which is compliance- is happening.
Levi Wiggins: So as we kind of peer over the garden wall here into Sutter Health’s dealings, obviously, no admission of wrongdoing was made in a $90 million settlement, but from out here, what do you see that they could have, or should have done differently or better?
Farshid Kazi MD: I think if you think about risk adjustment strategies, when you think about it in a pyramid, the foundation on which you build risk adjustment should really be around empowering, educating, and giving knowledge transfer to providers so that they can make clinical decisions.
So what is it that they’re doing? Why are they doing it? And then what should they do if they see a mistake? And so if that foundation was built, I suspect that the providers would be able to stand up and say, “Hey, some of these diagnosis that you’re putting it in front of me are inaccurate!” And a big mistake that was seen not only at Sutter, that I see across the United States, is acute diagnoses are being carried over year over year.
Meaning things like acute stroke, acute heart attack. That should not be coded in a patient the next year – or a malignancy that’s been resolved. And again, being carried over because someone gave a fax paper or a piece of paper to a doctor and said, can you please check yes or no to these diagnoses?
And maybe the provider thought, “Hey, the patient did have this at some point” But didn’t realize that this is not something that happened this year. And that’s up to, again, building the knowledge around what you’re trying to do. Putting the infrastructure in place so that you’re catching and saying, “Look, an acute diagnosis carried over year over year. Let’s go back to this provider. Did this patient really have two strokes? Two consecutive years?”
Maybe it’s yes. Maybe it’s no, but there needs to be a process around catching that. So I think building knowledge, having point of care workflow to empower your docs and then really building a solid foundation around compliance is going to be key.
Levi Wiggins: That’s good. I like that. One thing that we saw in this specific case is they were accused of intentionally coding unsupported diagnoses, and then finding them and not paying back – on purpose. So when we talk about increasing accuracy, talk to me a little bit about the process. I guess how you run a business, looking at money you’ve you’ve gotten and how to give that back in a way that’s ethical and reasonable.
Farshid Kazi MD: Yeah. I mean, it’s really hard to give money back once you’ve gotten it. So the best approach is really, don’t take the money if you’re not deserving of it. So really making sure that before the diagnoses go to claims, and then go to the payors, and then Medicare, you know, with full confidence, that they actually existed in the patient chart.
So one thing I always coach and work with provider groups is saying, what are the diagnoses that are acute? You don’t want to carry over and make sure that’s a no-no. But the second piece is let’s talk a little bit about, at the point of care. As the doctor’s writing the note, is there a way to catch and make sure that there’s compliance there before you even submit the bill?
And if not, let’s make sure we’re doing some audits and charts to give some confidence to you as an organization that you’re not receiving any reimbursements for diagnoses that are inaccurate.
And then the second piece to that is once you’ve done, that is having a retrospective aspect of let’s do some charts on. Let’s look through this and make sure we’re paying back appropriately because compounded over time. That can be a massive bill as well.
Levi Wiggins: Okay. So as we, as we look into the future here I mean, the whistleblower case is, is one avenue. The RADV audits are another avenue. But I guess what, what is, what is the risk level for, for a doctor? Like, what’s the likelihood of getting caught at this point.
Farshid Kazi MD: Yeah. You know, is something morally wrong only if you get caught, right? We could talk about that forever. But to me, it’s a question of do the right thing. The first time around. I think all providers have gone into the field because of that same level of commitment to their patients.
So if you are in value based care, because you care about delivering better care. And you think you can do it at a lower cost. Risk adjustment is a necessary part of that, but do it right the first time. So document accurately. And I think that the two pieces that provider groups should be worried about is there’s a significant risk to them.
That Medicare is going to now start to audit provider groups as the risk is passed from payors to provider groups. And the two things that I see all the time that providers are doing incorrectly is one, they’re carrying over acute diagnoses. And two, when they’re putting the diagnoses in there, they’re not necessarily justifying it.
They’re being told by their group that, “Hey, these diagnoses might exist. Do you agree?” And in order to move through the day, they say yes, but the diagnosis, maybe technically doesn’t meet Medicare guidelines, or doesn’t meet clinical guidelines. And that is not being audited, right? Yeah. And I don’t think that’s going to be very far off from when Medicare says, not only do you have to be compliant from a technical perspective and the pieces of your documentation, but Hey, the definition of the medical problem needs to be there.
Does the patient really actually have that diagnosis?
Levi Wiggins: So we published the white paper on RADV audits, but the principles from that should be just as applicable to provider groups. And I want to just touch on those. One thing. Our paper determined was the provider behavior is the first thing to fix. And that’s, that’s the education piece.
The next thing we, we determined was that proper documentation fixes nearly everything. You know, you mentioned that if you document something that isn’t, you know, maybe it was well-documented, but it wasn’t clinically accurate- that could spell trouble down the road, but right now, we just really need documentation to be on point.
The next thing we’ve determined is that without the proper tools in place, documentation is nearly impossible to get right. Another thing we did determine that certain codes get used erroneously more than others.
That’s also a very large terrifying gun to the head of a business. Is there anything I missed any any big takeaways we want to make sure we’re sharing.
Farshid Kazi MD: No. I think the whole process of auditing and checking is all limited by human capital.
Right? We don’t have enough hours in the day or people to help us check this, but as we enter into this next digital era of healthcare, where we’re in the midst, Technology can help you do that. Not only can you audit some sample size, but you can have good visibility to your entire patient chart and be able to say with full degree of confidence, that every chart that I’m documenting against has some type of technology or eye that’s been placed on it to make sure I’m compliant and making sure I’m not making a human error, which happens.
So utilizing technology to solve for some of the workflow gaps to solve for some of the knowledge gaps we’ll augment, not necessarily replace the strategies that are good compliant organization has. So making sure you build that in, and then having a clear safety net and allow people to be able to raise their hands, if they feel uncomfortable will be the key to making sure you’re compliant and then have, you know, you know, have good nights of sleep at the end because you’re know you’re doing everything right for the right reasons.
Need to learn HCC coding, and don’t want to sit through another lecture? Click below to demo the DoctusTech app.
Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.
We recently published a white paper on RADV audits and the importance of strict HCC compliance. A few weeks later, the Department of Justice announced a groundbreaking $90 million settlement with provider group Sutter Health.
In what looks to be a significant change of direction in RADV audit strategies, the DOJ has prosecuted a physician group.
False Claims Act allegations include “mischarging the Medicare Advantage program” and deliberately failing to pay back known overpayments. As a result, Sutter has agreed to not only a large financial settlement, but also five years of increased scrutiny and audits.
This settlement takes place only months after Sutter settled a much larger antitrust case with the state of California ($575MM according to Fierce Healthcare). For provider groups, this is more than a cautionary tale, it comes with a stern warning.
“Health care providers who flout the law need to know that my office will hold accountable those who pad their bottom line at taxpayer expense.” – Acting U.S. Attorney Stephanie M. Hinds
Acting U.S. Attorney Stephanie M. Hinds
For a group as large as Sutter Health, the $90 million is not much. Sutter received $812 million in payouts from the CARES Act; $900+ million in advance Medicare payments; and last year banked $13 billion in revenue. So all dollars considered, this settlement represents a mere 0.7% of Sutter’s annual revenue. However, for the whistleblower who stands to receive up to a quarter of those funds for her work with the DOJ, this is more than significant, it is life-changing. And for potential future whistleblowers, this case is both a legal precedent and a strong financial motivator.
And provider groups of all sizes need to take notice.
Much of the language in the DOJ’s press release reads more like a scolding than a legal case. As though The United States is not merely alleging financial misconduct, but expressing disappointment with the parties.
“The government alleged that Sutter Health knowingly submitted unsupported diagnosis codes for certain patient encounters for beneficiaries under its care. These unsupported diagnosis codes caused inflated payments to be made to the plans and Sutter Health. The lawsuit further alleged that, once Sutter Health became aware of these unsupported diagnosis codes, it failed to take sufficient corrective action to identify and delete additional unsupported diagnosis codes.”
In short, the DOJ alleges that Sutter deliberately coded unsupported diagnoses, got paid, knew about it, and didn’t pay back the overpayments.
“The government relies on healthcare providers, including those furnishing services to Medicare Part C beneficiaries, to submit accurate information to ensure proper payment… Today’s result sends a clear message that we will hold health care providers responsible if they knowingly provide or fail to correct information that is untruthful.” – Deputy Assistant Attorney General Sarah E. Harrington
No longer are RADV audits only a concern for payors, but providers will be held responsible for their HCC coding and the accuracy of their RAF scores.
“Today’s settlement exemplifies our commitment to fighting fraud in the Medicare program.” – Acting U.S. Attorney Stephanie M. Hinds for the Northern District of California.
From the tone of the DOJ’s own press release, this case is only the beginning.
“The knowing submission of inaccurate information to Medicare diverts funds from this vital health care program, which is a disservice to patients needing care… We will continue to work with our law enforcement partners to protect the integrity of federal health care programs and hold accountable entities who engage in false claims practices.” – Special Agent in Charge Steven J. Ryan for the Office of Inspector General of the U.S. Department of Health and Human Services
This may be the first case of its kind, but if the DOJ is to be believed, this will not be the last.
Also, as a condition of the settlement, no admission of wrongdoing has been made by Sutter Health and their affiliates. “The claims resolved by the settlement are allegations only and there has been no determination of liability.”
DoctusTech co-founder and population health expert Dr. Farshid Kazi will dig deeper into the ramifications of this case, and share resources and methods for avoiding a similar fate on the next installment of Live With Dr. Kazi.
Live with Dr. Kazi is a new video series from Value-Based Care expert, Farshid Kazi, MD – Co-founder of DoctusTech, and passionate advocate for HCC coding and the Quadruple Aim. In our third episode, Dr. Kazi shares ways in which HCC coding is good for the country.
Watch the full interview here!
I’m Farshid Kazi, co-founder of DoctusTech and an internist by training with a focus on palliative care.
I’ve built my career on population health out in California.
I’m excited to help other physicians looking to take the journey and leap into value-based care.
Levi: All right, we are back with another episode of DoctusTech thought leadership with Dr. Kazi. Hey, Dr. Kazi, how you doing?
Farshid Kazi, MD: Hey, Levi, doing well.
Levi: Today, I want you to talk about how, value-based care is generally good for our nation, the United States of America.
Farshid Kazi, MD: Yeah. The main thing people think about when it comes to healthcare is how do I one have lower premiums each month and have better outcomes.
But at a macro level, when we think about costs of care, that rises for a number of different reasons, but when it comes to value based care, you can solve both the personal side and the macro side. As long as we reinvest into taking care of our patients who are at risk for the highest chronic conditions, we’re going to do better as a country.
And a lot of that stems from giving patients choice and involvement in healthcare, which a hundred percent we stand behind. It doesn’t matter what field of medicine is. But sometimes having a clinician, that’s going to be able to spend a little bit more time to educate you, to teach you about the right definitions and what the decisions you have in front of you will allow you to make One) better decisions for yourself; but Two) more affordable decisions for the country.
And sometimes more is not better. And oftentimes when we think about your loved one, your grandma, your significant other even a child sometimes more is not better. That means tests, surgeries, exams, and a good clinician should be able to guide you through that. So from our country’s perspective, value-based care aligns incentives, performs better. And overall from a country’s perspective, you’ll have better outcomes.
Levi: Okay, one thing we talk about in the industry is the quadruple aim. And it seems like that is something that the value-based care HCC world can almost in one shot solve. Can you, can you speak to that?
Farshid Kazi, MD: Yeah. And I think we’ve broken this up nicely and some of the segments we’ve talked about already, right?
How do we make life better for your patients. So better care for individuals. How do we make a better care for all of the US, which is better population health and do that by lowering costs? I think sometimes the equation misses, and this is where quadruple aim comes in is how do we improve lives and balance for physicians?
So you have better care for patients, better care for the country at large or a population health perspective, better work-life balance for clinicians at lower cost.
Levi: And how do we fix that?
Farshid Kazi, MD: Yeah, I think you, you have to start with aligning incentives, right? And so when you think about the categorical shift, that payment happens through fee for service or your traditional model to value based care, where now clinicians are paid for outcomes.
All of a sudden you’ve aligned everything, patient outcomes to physician work-life balance, to lowering costs, and then better care for the population at large.
Need to learn HCC coding, and don’t want to sit through another lecture? Click below to demo the DoctusTech app.
Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.
Live with Dr. Kazi is a new video series from Value-Based Care expert, Farshid Kazi, MD – Co-founder of DoctusTech, and passionate advocate for HCC coding and the Quadruple Aim. In our second episode, Dr. Kazi shares ways in which HCC coding is uniquely good for doctors.
Watch the full interview here!
I’m Farshid Kazi, co-founder of DoctusTech and an internist by training with a focus on palliative care.
I’ve built my career on population health out in California.
I’m excited to help other physicians looking to take the journey and leap into value-based care.
Levi: Hey, Dr. Kazi, we’re back with another episode of doctors tech thought leadership.
So today we want to talk about. Value-based care, as it, as it relates to specifically benefits to the doctors, how is this good for you and your associates?
Yeah. I think as a provider, Levi, we in the fee for service world or the traditional sense of healthcare, get paid only when a patient can come in for a billable diagnosis.
I can have you come in because you’re sick, and bill the insurance company. They say, here you go, Dr. Kazi, which is great, but there’s so many aspects to keeping patients healthy that are not billing. Worrying about your diet, worrying about loneliness, worrying about your mental health.
And some of those components, I, as a clinician, wish I had either the time or the reimbursement to reinvest into your care. So as physicians are starting to transition into value-based care, They are now being reimbursed to care for their patient in a holistic way. And those are, I think, fundamentally the reasons all of us clinicians—it doesn’t matter what specialty you’re in—went into medicine, is how do I make sure that I make you healthier over time?
And so value-based care allows me to do that, which is quite relieving in, in many ways.
Levi: Now there’s, there’s the compassionate doctor side of the equation. And then there’s the aligned financial incentives side of the equation.
So as a physician owner, why is this good for you? Risk sounds risky. How does this work?
Dr. Kazi: Yeah. So everyone should not be taking risk upfront, which is a spot-on. It does sound risky, but if you want to practice medicine the way we all thought we would like to, when we were kids, value-based care is the right space to be in.
You don’t need to worry about the number of patients that you need to see every day. You need to worry about what their clinical outcomes are and by clinical outcomes, it means are they going to the hospital? Are they going to the ER, are they taking care of themselves? Preventatively?
And from a financial perspective, you’re getting a set run-rate on your revenue each year. So you don’t have to worry about how do I get my patients to come in, to see me. I’m rather getting a set budget that I can take care of my patient population.
And the ones that are sick and that you have a good relationship with, you’re going to be able to bring in more often than you would have been allowed in the traditional model.
So it helps you financially control your revenue. It helps you control your day to day. Decreases the burden of needing to see a ton of patients, which is why – number one reason people are burning out these days.
Levi: That makes sense. Okay. So at the risk of saying something that we would have to cut from this video later it seems like there’s potential financial upside for providers who enter into risk sharing contracts and code really accurately and document everything.
It seems to me that a doctor or practice could make more money and take better care of patients. Is that reasonable or is it, is it more profitable to just do fee for service?
Dr. Kazi: Yeah. It depends right? The clear answer is, it’s better to deliver good care and make profit, which is a hard thing to say.
And the traditional model, if you’re seeing 30, 40 patients a day, it’s really hard to stand by and say that you’re going to have better outcomes. And in fact, if you look at the data around. Patients that are in traditional Medicare versus patients who are Medicare advantage. They consistently outperform our quality metrics, meaning preventative screenings hospitalizations, total cost of care, which is just a reflection of outcomes on a clinical perspective.
So if you think about just where do you get your biggest bang for buck? It is on the value-based care side.
From a revenue perspective. Yes. If the doctor is taking better care of their patients, they will make more money, but that’s the right model of payment. Not necessarily just seeing more patients because you happen to be churning through a lot of sick patients.
Levi: That makes sense. And just to put a, put a little commercial break onto this: On average, what do we see from a DoctusTech perspective on increased reimbursements when coding is done correctly and recapture rates are at 95%, what does that look like per doctor, per year?
Dr. Kazi: And that could look… it depends on the contracts and they vary quite a bit, but you can look at five to six figures, per doctor per year, on top line revenue increase- if you’re just appropriately documenting.
And that’s, again, not talking about up-coding, we’re not talking about making sure you’re increasing a panel, but you should get paid for doing all the hard work you are.
And that is done through better documentation, which is where DoctusTech helps.
Need to learn HCC coding, and don’t want to sit through another lecture? Click below to demo the DoctusTech app.
Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.
