I used to be a "Risk Adjustment Auditor". Here's how it works...the Medicare replacement plans, get reimbursed by Medicare based on a few factors. One of them is based on how sick the patients are. This seems fair right...sick patients cost more. This data comes from the diagnosis codes you put on your claims.
This replacement plan has a patient named Joe. Joe had a claim a year ago that had the diagnosis of COPD on it...but the plan has not recieved a claim with COPD on it since then. His records are requested to see if he has seen the Dr for his COPD, and it just wasn't submitted. If it has, they will add the dx to your old claim. This will not affect YOUR claim payment, but will add to the replacement plans "Risk Score"...helping them get more money from Medicare.
Things may have changed since I did this a few years ago, but never did I see this result in any disciplinary action. Mostly just some education about diagnosis coding.
Sometimes they will ask you to review their findings and agree to coding changes. I believe it was in some contracts that they could use the records to make changes without your permission (to dx codes only)
I have seen their coders look at a record that said "problem list reviewed"...and even though a patient was there for a back problem, and no mention of a certain chronic illness mentioned, they would use the problem list to add diagnoses to the claim.
But there were also good "markets" that let their coders be proactive and actually give hands on coding education to the doctors, and also some that provided bonuses based on the reviews.
So the door swings both ways. I chose to take my career in a different direction. Please private message me if you have any other questions!
Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC
PMCC Licensed Instructor
Kansas City, MO Chapter
Member Development Officer 2016
Harrisonville, MO Chapter President - 2013
ICD-10 Education Coordinator- 2012
Chapter President - 2011
President Elect - 2010