Coding, MA Risk Scores, and Audits - Medical Coders Beware

by  Find-A-Code™
Jan 23rd, 2023

We are all aware of the fact that medical billing codes ultimately determine how much insurance companies and other payers fork out to cover medical costs. We also know that audits are part of the program. That being the case, medical coders need to be aware of increased scrutiny involving Medicare Advantage (MA) risk scores that may be used to inflate reimbursement rates.

According to a recent report that was published on the Medpage Today website, the Department of Justice (DOJ) is starting to take a closer look at MA risk scores and the potential for medical billers to inflate them in order to get higher reimbursements. Apparently, inflating the scores has become an issue due to the way MA is set up.

Not Fee-For-Service

Though there are numerous differences between Medicare and MA, the main difference from a billing standpoint is the fact that MA is not a fee-for-service plan. MA plans are reimbursed by the government at a flat rate determined partially by patient risk. On the other hand, traditional Medicare is fee-for-service.

MA has been set up this way to ostensibly prevent medical providers from recommending unnecessary services in order to boost payments. The flat fee system is designed to encourage the most appropriate care rather than the largest volume of services. Unfortunately, there are still ways to get higher reimbursements – one of them being inflating MA risk scores through medical coding.

The problem has gotten serious enough to lead the CMS to impose a nearly 6% reduction on all MA risk scores in order to bring MA reimbursements more in line with traditional Medicare. Meanwhile, the Medicare Payment Advisory Commission did a study and discovered that MA risk scores were, on average, 9.5% higher than comparable Medicare risk scores across the board.

Be Sure About Your Codes

As a medical coding specialist, you have very little control over what clinicians do. And though you work with medical billers as a normal part of your job, they ultimately decide what goes on a bill. Your part is to be very sure of the codes you utilize in your work. According to the Medpage Today piece, it is no longer enough to just choose a code and move on. Coders need to be sure to choose codes that can be justified with clinical documentation.

In other words, no more 'upcoding'. Granted, medical coders rely heavily on electronic health records (EHRs) prepared by clinicians. As a coder, you can only work with the information you are given. Do your best to be completely accurate with your codes at all times. If you ever have questions, do not be afraid to ask.

As for the EHR, it was originally intended as a vehicle to take American medicine away from the fee-for-service model and toward a new model that focuses mainly on patient satisfaction. Instead, it seems to have become little more than an electronic data set through which clinicians give coders and billers the raw data necessary to produce bills.

More Audits Are Coming

The underlying message from the DOJ is that more audits are coming. CMS knows that upcoding is going on. The Commission knows it is going on, too. It's only a matter of time before DOJ audits start producing big headaches for healthcare providers who think nothing of optimizing their medical codes for higher reimbursements.

If you are a medical coder, just be aware of all of this. Do your best to maintain the utmost integrity and accuracy in your work. Make sure everything you do is on the up and up.