Q. Does Medicare Part C function in the same manner as Medicare Part B?

A. No. Although the Centers for Medicare & Medicaid Services regulates Medicare Part C (also known as “Medicare Advantage” plans), they are separate. Medicare Part B is a straight fee-for-service plan, whereas Medicare Part C often operates with a managed-care plan approach. Medicare Part C plans often include coverage for services not covered by traditional Medicare Part B; for example, dental, vision, hearing, preventive care and additional supplemental services.  

Q. Is beneficiary enrollment in Medicare Advantage plans growing?

A. Yes. In 2007, 8.4 million beneficiaries had Medicare Advantage plans. By 2014, this number had grown by 7.3 million people, with 15.7 million beneficiaries enrolled in a Part C plan. The budget is now $156 billion, 30 percent of total Medicare spending.  

Q. Who pays private insurance companies to manage Part C plans?

A. CMS pays the Medicare Advantage plan for each subscriber. The beneficiary’s predicted health status and demographics (e.g., age, gender, disability status) determine the amount of payment to the plan. This process is called “Risk Adjustment.” It dictates payment to the plans with greater accuracy by predicting the beneficiary’s health-care costs.  

Q. How do the plans collect data on an individual patient?

A. Diagnosis codes submitted on claims, along with medical record documentation from inpatient and outpatient facilities and physician offices, provide the necessary risk adjustment data.  

Q. How does CMS determine the accuracy of the risk-adjusted payments they make to the managed-care plans?

A. CMS engages vendors to perform Risk Adjustment Data Validation (RADV) audits to maintain the accuracy of the risk-adjusted payments and the reliability of the data submitted. The medical record must support the diagnosis codes submitted for payment. Advantage plans may be selected annually for RADV audits.  

Q. Who provides the information to the Advantage plan for submission to CMS when the plan is audited?

A. Providers assist the plan by submitting requested medical records to the Advantage plan when the plan is being audited. Often, the records requested are those of patients with numerous diagnoses. By submitting data on these patients, the plan increases the risk score for its patients, which will increase its risk adjustment payment.  

Q. Should we assume that any records request from an Advantage plan is for a RADV audit?

A. No; these plans can and do conduct traditional audits seeking to confirm the medical necessity of a service and/or the proper level of coding, as well as the accuracy of CPT codes submitted for reimbursement.  Providers should carefully review the records request. Most risk adjustment audit letters indicate the purpose of the review; if in doubt, contact the vendor performing the audit and ask.  

Q. Do I need patient consent to release medical records for a RADV audit?

A. In general, no. The Health Insurance Portability and Accountability Act allows sharing of medical records with payers. In addition, most practices request patients sign a release of information form when the patient presents for the first time. This form typically states to patients that insurance companies may request clinical information such as diagnoses, treatment plans or copies of their entire medical record. By signing the form, patients provide consent for you to release this information.  

Q. How many records are requested by the plan to satisfy a RADV audit?

A. The plan may request a small number but it may also request a very large number; no magic number exists. The vendor performing the review may want to send one of its reviewers to your office to collect the data. They cannot take original records but may scan, copy or download them. You can refuse this option and prepare the records yourself, but it is often time-consuming for the staff to do this. You also have the option of contacting the vendor and asking to reduce the number of requested records or for an extension if the deadline for submission is unreasonable. In some states, you are permitted to seek payment from them for the costs associated with preparation, staff time and copy costs.  

Q. What types of errors are found during a risk adjustment audit?

A. Audits often reveal the following errors, which are easily avoided if providers and staff document appropriately and take the time to review their documentation and coding:

• The medical record is unsigned or not authenticated with an electronic signature if the practice uses EHR.

• The diagnosis code submitted lacks specificity or is not coded to the highest degree of specificity.  

• Documentation does not support the reported diagnoses.  

• No distinction is made between chronic and acute conditions, when applicable.  

• No documentation to indicate that a patient’s condition is being treated, monitored, assessed or addressed.
• Failure to report manifestation codes.  

Q. Will the ICD-10 coding system improve the data submitted to CMS?

A. Maybe. Because ICD-10 codes are extremely specific, CMS stated in 2009 that it believes that ICD-10 will facilitate the following:

• more accurate payment for new procedures;

• fewer rejected or improper claims;

• better understanding of new procedures; and

• improved disease management.

Q. Should we include patients with Medicare Advantage plans in our internal and external chart review process?

A. Yes. Chart reviews are an integral part of a compliance plan and provide an opportunity to improve the practice’s documentation and coding for all payers.  REVIEW

Ms. McCune is vice pres­ident of the Cor­coran Con­sult­ing Group. Con­tact her at DMcCune@corcoranccg.com.