DOJ Audits And How DoctusTech Helps
The Department of Justice has filed a new lawsuit against Cigna for overcharging the federal government by purposefully inflating how sick its Medicare Advantage members are.
Federal prosecutors previously declined to intervene in this whistleblower case, but have now seemed to change their minds about it.
The lawsuit brings up a very important point: Medicare fraud is a widespread practice. This lawsuit has just been another push by the government to crack down on insurers who exaggerate enrollees’ conditions in order to get more money from Medicare.
Over the past 2 years, the DOJ has joined separate, similar lawsuits against Medicare Advantage plans run by Kaiser Permanente and Elevance (formerly known as Anthem) and settled cases with several other similar organizations.
The lawsuit focuses on risk adjustment
The lawsuit focuses on risk adjustment – a process in Medicare that pays insurers more if patients are sicker than average. Some patients are assigned a higher ‘risk’ score’ than others due to conditions like diabetes, heart disease, etc.
Risk adjustment is a program to encourage insurers to cover people who might be considered a higher risk, even though they might be healthy. However, the current risk adjustment program also gives incentives to insurance companies and their vendors. They may prioritize coding diagnoses and bundling them together depending on your age or other factors.
The lawsuit specifically claims Cigna abused in-home assessments, where nurses and other clinicians go into a patient’s home and conduct health screenings.
The DOJ said Cigna’s home visits were designed to generate revenue for Cigna, not to provide medical care or treatment. They cited several instances in which people were diagnosed with things like rheumatoid arthritis but never received the blood tests they needed to confirm the diagnosis.
The practice of adding more conditions without verifying their accuracy is illegal. Every year, insurers have to attest to Medicare that they are following the rules and practices set by them. The overall practice is extremely profitable for Medicare Advantage insurers – potential profits could be thousands of dollars per year for just one patient.
The lawsuit by the DoJ is a cautionary tale on why it is imperative and critical for healthcare service providers to make their doctors compliant by coding accurately, documenting everything and providing proper justification.
How DoctusTech Helps Protect Against Actions Like This
HCC Coding Education in an app: DoctusTech helps train clinicians on proper VBC diagnosis requirements in a fun and engaging app. Through clinical vignettes and gamification, doctors learn quickly and accurately how to diagnose for risk, which HCC codes to use for what, and how to meet MEAT standards on all documentation. Learn how the DoctusTech app can help keep your team compliant today.
HCC Coding Implementation In Your EMR
DoctusTech Patient Data Analytics Platform: The PDAP sits inside your EMR and provides a simple pathway to capturing unique accurate diagnosis codes, recapturing appropriate past codes, and document appropriate MEAT standards were met to ensure highest data integrity and audit preparedness. To assist admins manage recapture codes across the organization, the integrated solution provides an Admin Portal that lists the recapture rates across clinic, provider, and patient level. This ensures that you have all the necessary information at your fingertips on clinics, providers, and patients as it relates to HCC coding, documentation, accuracy, and more.
