Representatives from The Office of Inspector General (OIG) presented at this year’s Risk Adjustment Innovations Conference and provided some interesting insight into their audit process. They are currently doing targeted audits on 12 areas and growing. Targeted audits are different from general Risk Adjustment Data Validation (RADV).
The typical progression of an OIG case begins when the department receives a tip or discovers a reason to do an initial look. They do some macro data analysis to look for anomalies and potential issues. When they find suspect patterns in the data, they then dig into individual charts and patients for further review.
One area the OIG is specifically looking at right now is “history of” codes being coded as current diagnoses. They find these by identifying instances where a diagnosis code is being coded but is not accompanied by an inpatient CPT. For example, an embolism diagnosis with no anti-coagulant prescription would raise a flag.
Another scenario they come across a lot involves accidental misdiagnosis. For example, a patient is originally diagnosed with a stroke based on symptoms. Upon further evaluation, it turns out it was something else (i.e., a pinched nerve). If the stroke diagnosis code stays on the claim submitted in this case, it’s inaccurate risk-adjustment coding. While this isn’t nefarious or intentionally fraudulent, it’s still something the OIG is looking for.
The OIG also provided the most shocking statistic of the conference. According to their presentation, when they zero in on a certain subset of coding discrepancies and do a full audit, they find that fully 69% of the HCCs captured are not supported by documentation. Furthermore, in only 3% of these instances does the offending payer or medical group challenge the OIG’s logic. This means 97% of the time the payer or medical group is essentially admitting that they made a mistake or, worse, committed fraud. For certain conditions like heart attacks, the percentage not supported by documentation can be well over 90%.
Social Determinants of Health (SDOH) were also a big topic at the conference. Homelessness has recently been designated a comorbidity. A recurring theme of this conference was the prediction that SDOHs are going to factor into risk-adjustment models soon. It’s not yet clear exactly how, but there is unanimous agreement that SDOHs are a risk-adjustment factor and should have financial implications.
Another overarching theme was that providers should just be focused on documenting. Training providers on new risk-adjustment models is not an effective use of time because these models will keep changing. Instead, groups should be focusing on helping providers to document properly and letting coding workflows do the rest. The OIG was also on board with this and reaffirmed that as long as the providers document it, there won’t be any issues with codes being added or removed.
