Friday, May 10, 2013

OIG: Cigna overbilled Medicare Advantage for $28M in 2007

OIG: Cigna overbilled Medicare Advantage for $28M in 2007

Cigna Healthcare of Arizona, a subsidiary of national insurer Cigna providing Medicare Advantage plans, overbilled Medicare by about $28 million in 2007, according to a new report released last week from the U.S. Department of Health & Human Services Office of Inspector General.
The OIG determined that Cigna submitted diagnoses to HHS for its risk score calculations that didn't always comply with federal requirements. Of the 100 beneficiaries in the sample OIG analyzed for the report, 40 had invalid risk scores because either the documentation didn't support the associated diagnosis or the diagnosis was unconfirmed.
Because Cigna's contracts require its providers submit accurate claims, the insurer assumed all providers were submitting accurate diagnoses as well. But the OIG said providers often report incorrect diagnoses or report diagnoses for conditions that didn't exist when providers treated the beneficiaries.
Based on its investigation, the OIG said Cigna must repay at least $151,000 in improper charges. The federal auditor also recommended that HHS conduct a more in-depth review of the disputed payments. Also, CIGNA needs to bring its "significant error rate" into compliance with federal rules, the report said.
"For one beneficiary, Cigna submitted the diagnosis code for 'congestive heart failure, unspecified,' " the report said. "However, the documentation that Cigna provided indicated that the beneficiary visited the physician because of knee pain. The documentation did not support the diagnosis of congestive heart failure."
Cigna, however, disagreed with the OIG's findings. In a written response to the report, Cigna said the OIG didn't properly account for frequent disparities in charges shown in claims data and in medical records. What's more, the OIG should have analyzed more medical records in its sample and taken a different statistical approach, both of which would have resulted in Cigna owing a total of just $440,000.
HHS will review the report and decide whether to implement the OIG's recommendations or take separate action. Cigna can appeal the report's findings.
To learn more:
- here's the OIG report

Clinical Documentation Improvement Tips - HCC Coding

Clinical Documentation Improvement Tips - HCC Coding

* Clinical Documentation Improvement will be the key to a successful transition into ICD-10.
Over the last two years, I have been teaching medical professionals how to code and document compliantly - specifically HCC Documentation and Coding.

I have listed below the most common errors that I find when auditing medical records. 

• Don’t document “H/O” of any disease that currently exists.
– The statement “history of” in ICD-9 terms means that the patient no longer has this condition. However, “H/O” is ok when documenting some status conditions such as an Amputation, Old MI or Cancer
• Rule of thumb in coding is
– If a patient is on a medication for a condition and if the medication were to be stopped, would the condition resume, and the answer is mostly likely or yes, then you still code the condition.

– H/O CHF – pt is on lasix 428.0
– H/O Angina – pt has nitroquick 413.9
– H/O COPD – pt is on Advair 496
• This also applies to a pacemaker for SSS or Complete or 3rd degree heart block…if the SSS or Heart Block is documented you can still code it 427.81 or 426.0


• Alcohol dependence, Chronic alcoholism or Alcoholism in remission 303.90 & 303.93
• Drug dependence or Drug dependence in remission
• (opiate, anxiolytic, sedative, hypnotic, hallucinogen or amphetamine) 304.90 & 304.93
• Patient has arrived at a stage of physical dependency and would experience physical signs of withdrawal with sudden cessation
 **Alcohol abuse and drug abuse are not HCC’s 305.XX

Major Depression 296.XX

– PHQ9 score >10
– 5 of 9 DSMIV criteria
– Medication
– Following with a mental health provider
– **if only “Depression” 311 is documented…it is not an HCC code!


Must have current treatment to the site
Treatment to the site is considered:
• Chemotherapy, Radiation or Adjunct therapy
• Or if patient elects not to have any treatment
Breast Ca (174.9) – on Tamoxifan, Arimidex, Femara etc. would be considered adjunct therapy
• Documentation needs to say “Breast Ca onTamoxifan”
• If not then H/O Breast cancer V10.3
Prostate Ca (185) – on Lupron, Casodex or Zoladex would be considered adjunct therapy
• Documentation needs to say “Prostate Ca on Lupron”
•If not then H/O Prostate Ca. V10.46


• Mets is the highest HCC $17,753 only if the site it has metastasized to is documented
– H/O Breast Ca with Mets to lung V10.3 & 197.0
– Prostate Ca on Lupron with bone Mets 185 & 198.82
– H/O Colon Ca with Mets to the liver V10.05 & 197.7
If you document like this the highest HCC opportunity will be missed

– Metastatic Breast Ca $1622 (if Breast ca is under treatment) 174.9 & 199.1
– Metastatic Colon Ca $1622 (if Colon ca is under treatment) 154.0 & 199.1
– Lung Ca with Mets $8213 (if Lung ca is under treatment) 162.9 & 199.1
– H/O Lung Ca with Mets $1622 V10.11 & 199.1


Acute condition that can only be documented and coded during the initial episode of care – 434.9X
– Once the patient is discharged from hospital documentation should reflect:
  “h/o CVA, s/p CVA or Old CVA V12.54”
• Late effects of CVA should be documented and coded as such
– CVA with hemiplegia/hemiparesis 438.20
– CVA with dysphagia 438.82


Acute DVT (initial episode of care)
– 453.40
Chronic DVT (on an anti-coagulant)
– 453.50
H/O DVT (not on an anti-coagulant)
– V12.51
Need to document “chronic DVT” if patient is on an anti-coagulant
*** Same guidelines for Pulmonary Embolism


• Artificial openings
– Gastrostomy V44.1
– Colostomy V44.3
– Tracheostomy V44.0
– Ileostomy V44.2
• Amputations
– BKA V49.75
– AKA V49.76
– Foot V49.73
– Toe V49.71 or V49.72
• AAA – Abdominal aortic aneurysm – 441.1 (w/o repair)
• Aortic Atherosclerosis – 440.0

Contact Kameron Gifford, CPC at ERM Consulting for a free Revenue Risk Assessment 

Health Systems Management Network, Inc Publishes Findings About Changes in Hospital Billing and the New Penalties Under the Affordable Care Act That Will Be in Place in 2015

Health Systems Management Network, Inc Publishes Findings About Changes in Hospital Billing and the New Penalties Under the Affordable Care Act That Will Be in Place in 2015

The Wall St. Journal in a recent article by Stephen Soumerai and Ross Koppel stated that CMS is very focused on reducing rates of readmission of Medicare/Medicaid patients.
Wellington, FL -- (SBWIRE) -- 05/09/2013 -- The Wall St. Journal in a recent article by Stephen Soumerai and Ross Koppel stated that CMS is very focused on reducing rates of readmission of Medicare/Medicaid patients. These findings along with the changes in hospital billing and penalties applied under the Affordable Care Act are now published on the Health Systems Management Network, Inc (HSMN) website.

Findings from the Wall Street Journal article include the following conclusions:

1) Research shows that most readmissions can’t be prevented;
2) Readmission penalties which will be 1%-3% starting in 2015 will incentivize hospitals to keep patients in the emergency room rather than admit;
3) There will be a temptation to change the coding for patients that are readmitted to indicate that they were not admitted with the same Dx or infection;
4) Hospitals serving poor communities will be severely hurt financially.

The authors of this article promote a team approach in which a physician and nurse practitioner can help manage patients better at home. However, if the patient must be readmitted HSMN’s own finding is that that clinical documentation does not always measure up to the need to support readmissions.

Under ICD-10-CM/PCS it will grow increasingly difficult to justify readmission if there is not a significant improvement to the clinical documentation supporting the readmission. Health Systems Management Network, Inc. has worked with many Medical staffs on clinical documentation in it’s almost 30 years of Consulting.

HSMN’s consulting engagements have been clinical documentation projects centered on both the clinical and coding staff. These client engagements have improved revenue and reduced denials by significant margins. In the new ICD-10-CM world significant improvements to both the quality of and the specificity are critical elements for revenue success. The new scenario requires such specificity that any omission will result in denial of payments and penalties to reimbursement.

HSMN has begun a “Start Ten Program” which focuses its efforts on the clinical documentation of the medical staff and its’ partnering with coders who must use both knowledge and critical thinking skills.

“Because of our vast experience in case management and utilization over the past 30 years we are coupling our Start Ten Program with our Patient Focused Clinical Documentation Improvement Program.”

The “program” has been developed with the help many of the best clinical minds in our country. The purpose of the Program is to focus the entire clinical team on patient problems/diagnoses with a view to integration and specificity required by ICD-10-CM. Clearly the integration of care would leave no doubt about the need for the current admission and its treatment and this must be reflected by the “Team” in its clinical documentation.

Health Systems Management Network, Inc. thus announces the “The Start Ten Program Plus”.

Please contact our offices 866-908-4226 or email for a consultation on how HSMN can be of service to your organization. This initial teleconference consultation is without cost.

Media Relations Contact

Theo Tarantini
Health Systems Management Network, Inc.

Vitera Healthcare Solutions Sponsors MediFuture 2023 Conference

Vitera Healthcare Solutions Sponsors MediFuture 2023 Conference

Vitera’s innovative healthcare technology can help lead the way in making Tampa Bay the nation’s healthcare innovation capital
TAMPA, Fla.--()--Vitera Healthcare Solutions, the nation’s premier provider of ambulatory electronic health records (EHR) and practice management software and services, today announced its sponsorship of MediFuture 2023, an event designed to position the Tampa Bay region as the epicenter of “disruptive innovation” in healthcare.
“We’ve been the leading innovators in healthcare technology for more than 30 years, now headquartered right here in Tampa Bay”
The one-day conference will be held May 13, 2013, in Tampa, Florida.
The inaugural conference, presented by the Tampa Hillsborough Economic Development Corporation, intends to inspire innovative thinking and new technologies that can be used to promote the region as a place where “tomorrow’s healthcare happens today.”
“We’ve been the leading innovators in healthcare technology for more than 30 years, now headquartered right here in Tampa Bay,” said Matthew Hawkins, CEO of Vitera Healthcare Solutions. “We continue to develop clinical and financial software that is transforming the healthcare industry. Naturally, we welcome area leaders to join us in positioning Tampa Bay at the forefront of healthcare innovation.”
Vitera ranks 36 among the nation’s top 100 healthcare vendors, according to Healthcare Informatics, and was recently ranked the No. 1 software developer in the Tampa Bay Area by the Tampa Bay Business Journal. The company has a long legacy of innovation, having introduced the first practice management solution for physicians, and the industry’s first-generation electronic health record solution.
Today, Vitera continues to provide physicians with tools they need to successfully manage their practices amid industry and regulatory changes, including electronic health record solutions that help office-based practices improve patient outcomes.
Electronic health records make it possible for medical professionals to collect, access and analyze huge amounts of medical data, so they can more accurately predict when patients are at risk.
“The goal of improving patient health—while decreasing costs—is virtually impossible without proven electronic health record and integrated practice management solutions,” Hawkins said.
To find out more about Vitera’s solutions and the company’s commitment to preparing practices for the future of healthcare, visit