Highlights
A federal court recently interpreted the International Classification of Diseases (ICD) Guidelines to require that diagnoses added through addenda must have required or affected patient care or management at the encounter
Defendants conceded that the ICD Guidelines “have the force of law”
The Ross holding reinforces that MAOs and providers should have robust compliance programs to ensure that retrospective reviews and the use of addenda comply with CMS guidance
A decision earlier this month allowing a case to proceed regarding alleged fraud by a Medicare Advantage Organization (MAO) and its subsidiaries signals the continued scrutiny of certain risk-adjustment practices in the healthcare industry.
The Honorable William Skretny of the U.S. District Court for the Western District of New York issued an order in U.S. ex rel. Teresa Ross v. Independent Health Corporation granting in part and denying in part the defendants’ motion to dismiss the government’s intervention complaint alleging the defendants engaged in fraudulent risk-adjustment practices relating to retrospective chart reviews and the use of addenda.
The government’s intervention complaint alleges that Independent Health Association, an MAO, and its subsidiaries overstated patient health conditions by submitting inaccurate and unsupported diagnosis codes in violation of Centers for Medicare & Medicaid Services (CMS) regulations and contractual obligations, which resulted in unwarranted overpayments....
UK consumers received GBP 3.5 billion in refunds due to friendly fraud over the past 12 months, according to emerchantpay. The company estimated that 6.5 million people received money back after m...