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The Biggest Fraud Found In Medicare – Ginny’s Blog

The Biggest Fraud In Medicare

Home Health Is Not The Only One Under The Microscope

We frequently hear about how bad the fraud is in the home care industry and of all the owners and physicians going to jail.  The following are excerpts from an article featured in the Rowan Report and I think it is worth reading.

“Specifically, the OIG report identified $2.7 billion in payments for services to MA beneficiaries that were never rendered.

In a response to a whistleblower complaint filed by an employee familiar with the company’s billing practices, a UnitedHealth spokesperson said, “the lawsuit showed that the Justice Department ‘fundamentally misunderstands, or is deliberately ignoring, how the Medicare Advantage program works.'” He added that “reviewing patients’ charts and correcting errors was ‘an appropriate and expected part of the Medicare Advantage program,’ and that questions about such activities ‘reflect at most a policy disagreement.'”

The whistleblower, James Swoben, informed investigators that United’s data analysis flagged opportunities to add diagnoses during chart reviews but ignored instances where the review might have removed diagnoses and lowered payments. Some of the complaints were dismissed by a federal judge in February 2018 but the department continues to pursue Swoben’s accusations about what the suit calls “one-way” chart reviews.

With this as a background, the HHS OIG’s December 10 report — that nearly all MA organizations add diagnoses during chart reviews but do not add corresponding services — takes on added significance.

Our findings highlight potential issues about the extent to which chart reviews are leveraged by MAOs and overseen by CMS. Based on our analysis of MA encounter data, we found that MAOs almost always used chart reviews as a tool to add, rather than to delete, diagnoses-over 99 percent of chart reviews in our review added diagnoses. In addition, diagnoses that MAOs reported only on chart reviews-and not on any service records-resulted in an estimated $6.7 billion in risk-adjusted payments for 2017. CMS based an estimated $2.7 billion in risk adjusted payments on chart review diagnoses that MAOs did not link to a specific service provided to the beneficiary-much less a face to-face visit. Although limited to a small number of beneficiaries, almost half of MAOs reviewed had payments from unlinked chart reviews where there was not a single record of a service being provided to the beneficiary in all of 2016. Our findings raise potential concerns about the completeness of payment data submitted to CMS, the validity of diagnoses on chart reviews, and the quality of care provided to beneficiaries.”

Despite the potential for MAOs to misuse chart reviews, CMS has not reviewed the financial impact of chart reviews in the encounter data on risk adjusted payments. CMS also has not yet performed audits that validate diagnoses reported on chart reviews in the encounter data against beneficiaries’ medical records. CMS reported that it plans to begin audits that would include such chart reviews later this year.”

Something to think about isn’t it?

Ginny Kenyon

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