Revenue Audit and Monitoring Program (RAMP™)

Late last month, in Modern Healthcare, Jessie Hellmann writes that Jonathan Blum of the Center for Medicare and Medicaid Services (CMS) now echoes the concerns of those in the Office of Inspector General (OIG) regarding risk adjusted revenue integrity. According to an OIG report, some Medicare Advantage Organizations (MAOs) may have leveraged chart reviews and Health Risk Assessments to potentially exaggerate the negative health status of members. Because revenue in the program is risk adjusted, these representations have likely resulted in excess and inappropriate revenue for the MAOs.

“Unsupported risk-adjusted payments have been a major driver of improper payments in the MA program,” said Blum.

Blum also expressed concern for “the overall trend lines for code growth in the MA program vs the fee-for-service program” and mentioned possible regulation.

The OIG noted a specific finding that “… 20 of the 162 MA companies drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and HRAs, and on no other service records.”

Much of this derives from OIG’s December 2019 report entitled “Billions in Estimated Medicare Advantage Payments from Chart Reviews Raise Concerns.” To develop this report, OIG cites this review methodology:

We analyzed 2016 MA encounter data to determine the 2017 financial impact of diagnoses reported only on chart reviews and not on any service record in the encounter data that year. We also analyzed CMS’s responses to a structured questionnaire to identify actions taken by CMS to review the impact of chart reviews on MA payments.

With this report in mind, OIG made the following recommendations to CMS:

(1) provide targeted oversight of MAOs that had risk-adjusted payments resulting from unlinked chart reviews for beneficiaries who had no service records in the 2016 encounter data.

(2) conduct audits that validate diagnoses reported on chart reviews in the MA encounter data.

(3) reassess the risks and benefits of allowing chart reviews that are not linked to service records to be used as sources of diagnoses for risk adjustment. CMS concurred with these recommendations.

FRG believes that health plans and physician groups managing risk for Medicare Advantage populations need significant risk adjusted revenue to sustain the expected costs of care, particularly due to the lag in coding specificity on new enrollees and plan-transfer members. However, when diagnosis codes not captured in the course of clinical care delivery are used in the Medical Risk Adjustment (MRA) model, in favor of chart reviews, a very real opportunity for inconsistency occurs.

These inconsistencies can have significant consequences over time for MAOs and their aligned provider groups. When Hierarchical Condition Codes (HCCs) and Medical Risk Adjustment (MRA) scores presented in the CMS payment files, namely the Monthly Membership Report (MMR) and Model Output Report (MOR), are unsubstantiated by the antecedent claims and encounter feeds, they are at risk for retroactive downward adjustment in the mid-year and final payment cycle updates. Sometimes, these gaps in source diagnosis codes can be filled by seeking the documentation again from the RAPS or EDPS acceptance files in lieu of chart audits. But sometimes, these returns are not retained and validated with the same rigor as claims extracts and other expenditure documentation. Even when records are retained carefully by a single plan, record gaps can also be created when a patient transfers from one health plan to another, particularly when the receiving plan learns that the former plan was perhaps not submitting properly. Regardless, it is difficult for MAOs to know which patient records are at risk without a fine analysis.

Get an Audit!

It is with this backdrop and understanding the regulatory scrutiny that FRG offers its newest reporting service, the Revenue Audit and Monitoring Program (RAMP™) service. The RAMP™ service provides member-level analysis for each payment year and serves to document the supporting detail from encounter and RAPS records side by side with the CMS. Providing this level of analysis, a member level, payment year, and diagnosis source specific framework, is how FRG helps MAOs to ensure the appropriateness of their risk-adjusted revenue and address weaknesses in their accruals.

The obligation to document, recapture, and maintain accurate coding specificity to ensure proper risk adjustment of revenue under global capitation requires an active, ongoing monitoring process. – FRG