Compliance Essentials for Risk Adjustment: Navigating DOJ/OIG Activities

Summary

Risk adjustment is under unprecedented scrutiny, and you need to be prepared. Payments to Medicare Advantage organizations are risk adjusted based on the health status of each Medicare Advantage beneficiary. These payments are made based upon demographics and diagnosis codes. These payments are intended to cover the anticipated future resource needs of their members. Ultimately, plans are paid more for members with higher risk scores. Inflating risk scores by submitting inaccurate diagnoses codes can lead to overpayments. In recent years OIG and DOJ have identified that risk adjustment coding is an area that id susceptible to fraud.

This workshop will ensure that you understand how crucial a compliant risk adjustment program is for your organization. You will learn what OIG is targeting and hear about several high-profile DOJ cases. We will discuss strategies to ensure your program is compliant.

Learning Objectives/Agenda:

• Discuss the recent government agency scrutiny on risk adjustment
• Explain why compliant diagnosis coding is crucial for their organization
• Recognize what OIG is looking for in their Work Plan
• Understand the implications of the DOJ litigations
• Assess areas of possible audit vulnerability in their own organization
• Initiate a plan for ensuring compliance at their organization

Why is this topic timely/important?

Medicare Advantage covers 30.7 million lives and continues to grow. Risk Adjustment funds Medicare Advantage Plans and these payments ensure that proper payment is made to cover health care expenses for these enrollees.

There has been an increase on government enforcement of risk adjustment coding. The DOJ has filed lawsuits against health care providers for violations of the False Claims Act for submitting codes that were not supported in the patient’s health care record.

Who would benefit from this topic?

Anyone who is in the value-based reimbursement space. Employees of health plans, ACOs, MSOs, coders, auditors, and risk adjustment leadership

What’s your background/expertise on this topic?

25 years’ experience in all aspects of healthcare. I am a nationally recognized expert in risk adjustment and diagnosis coding and have spoken at countless conferences across the nation since 2015.

About The Author

Colleen Gianatasio, CPC, CPC-P, CPMA, CPC-I, CRC, CCS, CCDS-O

Collen has over 20 years' of experience in the health insurance field, including customer service, claims, quality, and coding. As director of ambulatory CDQI at Mount Sinai Health Partners, her primary responsibilities are provider engagement and CDI for accurate coding and reimbursement. Gianatasio specializes in developing innovative coding curriculum and instruction to support compliance with federal guidelines and appropriate reimbursement processes. She is a certified AAPC instructor and enjoys teaching a variety of coding, documentation, and auditing classes. She serves as president-elect of the AAPC National Advisory Board.