MAOs Are Facing Massive Fines For Over-coded Encounters
The EDI Project Can Help MAOs Find Them & Fix Them Before It Is Too Late
January 2023 – Shots fired by the Biden Administration
The press conference announcing the government was expecting to pursue Medicare Advantage Organizations for nearly Five Billion Dollars in fines was only the latest in over fifteen years of back and forth over the issue of how much MAOs should be compensated for Risk Adjustment.
However, the data is supported by the Office of Inspector General (OIG). It turns out, most plans have submitted ZERO DELETES of risk adjustment data since EDPS was implemented for collecting encounters. Perhaps worse - among the plans that do submit deletes, there was over a 100 to 1 ratio of Adds to Deletes even when they did. To the government, this represents a smoking gun.
To The EDI Project, this was a cry for help.
How bad is it?
After the announcement, it is reasonable for executives like CEOs and CFOs to want to know what their exposure might be. Perhaps they have to answer to shareholders about the potential impact to the business going forward. Many realized quickly, they couldn't answer the question from their own data.
As an example, a health plan who is just average - not some terrible offender - and has 100,000 lives would be facing a fine of almost $17 Million dollars!
This doesn't mean there is an active effort to defraud anyone. It simply reflects the reality that overcoded claims can easily get into your encounter data and once in there, they can be tough to identify and remove.
Challenges to Overcome
Flawed EDPS Systems
Many Encounter Data Processing Systems (EDPS) are either incapable of sending deletes, or if they are capable, the process is so convoluted, it is completely ineffective.
An Independent View?
If legal wanted to conduct an audit, they would have to ultimately rely on the very same systems to try and get an answer that sent the over-coded encounters in the first place.
Many efforts are one way only
Even organizations who invest in robust chart review processes, don't result in a delete of an overcode due to the many to one relationship of encounters to charts. You only need to do a single "add" to get a pickup of a new HCC code, but to delete a code, you have to find every instance of that code that has been submitted and back out each one. If even one slips through, the over-code will persist.
New systems take nearly a year to roll out and still may not address the problem
It isn't simple to switch away from an inadequate EDPS system due to all the systems they have to integrate with to function.
When everything is a priority, nothing is a priority
Projects with tens or hundreds of thousands of charts quickly obscure the problems and instantly lose focus. Where are the over-coded members?
The Governement doesn't care that it was an honest mistake
The vast majority of overcodes are taken directly from the providers claims / encounters. The MAO is still on the hook.
Actionable Results
Quick to implement
7 days from contract signed to live data
No Integration
Just send us copies of your CMS Submissions and Responses
Laser Focused on Deletes
We'll score all your HCCs and find the codes most likely to need to be deleted. Instead of being overwhelmed with thousands of charts needing to be retrieved and reviewed, we'll highlight the members who are most likely to be over-coded so you can prioritize.
No Capital Expenditure
This nimble solution is affordable and easily funded out of your operational budget. The payoff however, is massive.