OIG Testimony Puts a Spotlight on Clinical Documentation and Payer Risk

Summary of article from Ankura, by Emily Petersen:

In a recent testimony, the Inspector General of the Department of Health and Human Services (HHS), highlighted issues surrounding risk adjustment in Medicare Advantage (MA) and proposed stricter rules for diagnoses used in risk adjustment calculations. She underscored the issue of rising improper payments within Medicare and Medicaid, emphasizing the need for increased oversight and enforcement. Significant vulnerabilities in the MA risk adjustment process and challenges in Medicaid Managed Care were also discussed, with a call for organizations to review their medical records and ensure the accuracy of diagnosis codes. Furthermore, systemic weaknesses such as eligibility determination errors and duplicate payments were pointed out, requiring urgent attention. Lastly, Grimm emphasized the need for increased investment in oversight and enforcement to combat fraud, waste, and abuse in healthcare programs.