Kaiser Permanente allegedly forced employees to update applications for Medicare Advantage recipients, which resulted in approximately 75% errors, according to a new study. complaint from the US Department of Justice.
In July, the federal government intervened in six related lawsuits and filed a complaint on Monday about how Kaiser doctors allegedly changed medical records several months after providing assistance to increase Medicare Advantage reimbursement of an integrated health care system in Oakland, California. More than half of Kaiser doctors said they were forced to add diagnoses they did not consider, evaluate, or treat, according to one of the informants and former Kaiser medical coder Randy Osinek.
Kaiser said the system is MA compliant and will defend itself against legal claims to the contrary, marking nearly a decade of “excellence” in CMS audits for risk adjustment.
“Our policies and practices represent well-reasoned and conscientious interpretations of the sometimes vague and incomplete guidelines of CMS,” Kaiser said in a statement.
Here are five things to know about a DOJ complaint:
1. The Kaiser allegedly targeted aortic atherosclerosis or hardening of the arteries as a potential area with a “high rate of reimbursement.” Permanente Medical Group in Northern California allegedly told agencies that starting in 2012, 40% of their bonuses will depend on how well they have coded these conditions. The email, cited in a complaint between executives, states: “We’re missing out on a $ 40 million opportunity. In the current reality of a shrinking income stream, this would be devastating for us. What are we doing to improve? How can we customize the environment or create habits to bring us to 100%? Can we tell from the bright spots how they do it? How to rally a herd. Everyone joins the discussion. $ 40 million is no small thing. “
2. Some employees allegedly called the desire of the Kaiser to record as many diagnoses as possible “the desire for cash.” According to the complaint, the Kaiser would have organized “coding parties” where doctors would go through lists of diagnoses and add them to patient visit records.
3. Insurers are known to conduct retrospective reviews of the schedules for Medicare Advantage cases to maximize reimbursement, court documents show. Identifying and documenting additional diagnostic codes to be sent to the CMS for Risk Based Payment is legal with supporting documentation. ISPs claim they are coding correctly after years of “undercoding,” while critics claim they are cheating the system.
4. Kaiser allegedly did not conduct chart reviews for patients for whom they could not receive risk-adjusted payments. According to the complaint, Dr. Teresa Welch, medical director of coding for the Kaiser Colorado Medical Group, allegedly wrote to clinician supervisors that doctors should not “spend more than one minute requesting” because responding to requests was “like a top-up request. “and that she could do” two a minute. “Each added diagnosis allegedly cost the Kaiser about $ 3,000.
5. Some of the diagnoses that the Kaiser allegedly added through chart reviews did not even exist; many allegedly did not require or influence the patient’s care or treatment. These chart reviews were often added months or even a year or more after the visit so that Kaiser could receive risk-adjusted payments for newly added diagnoses, according to the complaint.