Wednesday, March 29, 2017

Transforming Clinical Practice Initiative

The Transforming Clinical Practice Initiative is designed to help clinicians achieve large-scale health transformation. The initiative is designed to support more than 140,000 clinician practices over the next four years in sharing, adapting and further developing their comprehensive quality improvement strategies. The initiative is one part of a strategy advanced by the Affordable Care Act to strengthen the quality of patient care and spend health care dollars more wisely. It aligns with the criteria for innovative models set forth in the Affordable Care Act:
  • Promoting broad payment and practice reform in primary care and specialty care.
  • Promoting care coordination between providers of services and suppliers,
  • Establishing community-based health teams to support chronic care management, and
  • Promoting improved quality and reduced cost by developing a collaborative of institutions that support practice transformation.

Since the launch of the Affordable Care Act, CMS has launched numerous programs and models to help health providers achieve large-scale transformation. Programs and models, such as the Hospital Value-Based Purchasing Program, Accountable Care Organizations, and the Partnership for Patients initiative with Hospital Engagement Networks, are striving to help clinicians and hospitals move from volume-based towards patient-centered quality health care services. This has resulted in fewer unnecessary hospital readmissions, reductions in healthcare-associated infections and hospital-acquired conditions, and improvements in quality outcomes and cost efficiency.
To date, there has been no large–scale investment in a collaborative peer-based learning initiative designed as an investment that ensures that clinicians who participate will be part of leading and creating positive change for the entire health care system. CMS estimates that only about 185,000 of the nation’s clinicians currently participate in existing programs, models, and initiatives that facilitate practice transformation.
The Transforming Clinical Practice Initiative is one of the largest federal investments uniquely designed to support clinician practices through nationwide, collaborative, and peer-based learning networks that facilitate large-scale practice transformation.
Initiative Details
Practice Transformation Networks

The Practice Transformation Networks are peer-based learning networks designed to coach, mentor and assist clinicians in developing core competencies specific to practice transformation. This approach allows clinician practices to become actively engaged in the transformation and ensures collaboration among a broad community of practices that creates, promotes, and sustains learning and improvement across the health care system. The following organizations are the Practice Transformation Networks:
  • Arizona Health-e Connection
  • Baptist Health System, Inc.
  • Children's Hospital of Orange County
  • Colorado Department of Health Care Policy & Financing,
  • Community Care of North Carolina, Inc.
  • Community Health Center Association of Connecticut, Inc.
  • Consortium for Southeastern Hypertension Control
  • Health Partners Delmarva, LLC
  • Iowa Healthcare Collaborative
  • Local Initiative Health Authority of Los Angeles County
  • Maine Quality Counts
  • Mayo Clinic
  • National Council for Behavioral Health
  • National Rural Accountable Care Consortium
  • New Jersey Innovation Institute
  • New Jersey Medical & Health Associates dba CarePoint Health
  • New York eHealth Collaborative
  • New York University School of Medicine
  • Pacific Business Group on Health
  • PeaceHealth Ketchikan Medical Center
  • Rhode Island Quality Institute
  • The Trustees of Indiana University
  • VHA/UHC Alliance Newco, Inc.
  • University of Massachusetts Medical School
  • University of Washington
  • Vanderbilt University Medical Center
  • VHQC
  • VHS Valley Health Systems, LLC
  • Washington State Department of Health

Support and Alignment Networks

The Support and Alignment Networks will provide a system for workforce development utilizing national and regional professional associations and public-private partnerships that are currently working in practice transformation efforts. Utilizing existing and emerging tools (e.g., continuing medical education, maintenance of certification, core competency development) these networks will help ensure sustainability of these efforts. These will especially support the recruitment of clinician practices serving small, rural and medically underserved communities and play an active role in the alignment of new learning. The following organizations are the Support and Alignment Networks:
  • American College of Emergency Physicians
  • American College of Physicians, Inc.
  • HCD International, Inc.
  • Patient Centered Primary Care Foundation
  • The American Board of Family Medicine, Inc.
  • Network for Regional Healthcare Improvement
  • American College of Radiology
  • American Psychiatric Association
  • American Medical Association
  • National Nursing Centers Consortium

Support and Alignment Networks 2.0
A second round funding opportunity announcement of the Support and Alignment Networks (2.0) was announced on June 10, 2016. This opportunity will provide up to $10 million over the next three years to leverage primary and specialist care transformation work and learning that will catalyze the adoption of Alternative Payment Models at very large scale, and with very low cost. The Support and Alignment Networks 2.0 represents a significant enhancement to the TCPI network expertise and will help clinicians prepare for the proposed new Quality Payment Program, which CMS is implementing as part of bipartisan legislation Congress passed last year repealing the Sustainable Growth Rate.
Through this initiative, the Support and Alignment Network 2.0 awardees will identify, enroll, and provide tailored technical assistance to advanced clinician practices in order to accelerate transformation and diffuse this learning throughout the TCPI initiative. Support and Alignment Network 2.0 awardees’ activities, coaching, and technical assistance should result in the rapid transition of practices through five phases of transformation:
  • Set aims
  • Use data to drive care
  • Achieve progress on aims
  • Achieve benchmark status
  • Thrive as a business via pay-for-value approaches

The period of performance for the Support and Alignment Networks 2.0 is September 2016 through September 2019. The period of performance includes three 12-month budget periods. Support and Alignment Networks must achieve reasonable progress to the aims of the initiative as supported by their own proposed specific targets and milestones. Continued funding is contingent on adequate progress, compliance with the terms and conditions of the previous budget period, and the availability of funds.
For additional information, please contact

Rapid Practice Innovation (RPI) 

If your organization is participating in a TCPI Network or just looking to improve. ERM has a solution that is guaranteed to deliver results in just 24 weeks. 

Rapid Practice Innovation is an evidence based practice transformation program that ensures your organization is “risk ready.” Over the last 4 years, we have worked with medical practices, IPAs, MSOs FQHCs, health alliances, rural health networks and health plans to improve the delivery of care from the initial point of contact and sustain that change through RPI.

Two RPI Tracks for 2017 and 2018:
  • 24 Week Practice Transformation - Our proprietary 24 week curriculum re-designs the primary care office from the ground up to ensure success in the new world of value-based reimbursement. 
  • 52 Week "Risk Ready" Practice Transformation - This track combines the 24 week curriculum followed by 28 weeks of monitoring and follow-up for certification. Practices who successfully complete both the 24 week curriculum and the 28 week post-transition follow-up will be awarded a “Risk Ready” Certificate. 

Email Kameron Gifford at for more information.

Saturday, March 25, 2017

Advanced Risk Management and Office Based CDI Workshop


* Workshops Consistently Rated 4.9 / 5.0 Stars By Attendees *

§Review the different risk adjustment models and their impact on medical practice management.

§Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims?

§Take a deep dive into HCC Coding and Documentation. Review real examples to see what validates, what doesn’t, and why. Tips for engaging physicians.

§Learn how to leverage frontline staff to be successful in the world of risk adjustment and value based payments. 



Medical Coders and Billers
Providers / Medical Directors
CDI Specialists
Executive Leaders
Compliance Professionals
Health Alliance Members
Rural Health Centers
ACO, MSO and IPA Teams
Medicare Advantage , Medicaid and Commercial Plans

  • Clinical Documentation and Coding Guide  $ 99 Value
  • HCC Quick Coder (Mappings to ICD-10 Codes) for MA and Commercial Models
  • Risk Adjustment Workbook and Appendix with Easy to Use Templates
  • Laminated Coding and Documentation Tools 
WORKSHOP $399 –  EARLY BIRD $299 (Ends May 1st)


July 21, 2017 - Orlando, FL


Additional 2017 Workshops:

Boca Raton, Florida - September 12, 2017

Download Complete Agenda

Register for the Boca Raton Workshop

Ft Lauderdale, Florida - October 19, 2017

Download Complete Agenda

Register for the Ft Lauderdale Workshop

Visit to learn more

Wednesday, March 1, 2017

Could Retrospective Chart Reviews Constitute a False Certification for MAO Data?

Image result for person asking a question

Kameron Gifford, CPC 

For those who live in the world of risk adjustment there has been a great debate among industry leaders in regards to the use of blind coding in retrospective audits. For those unfamiliar with the term, “blind coding,” it refers to coding and auditing medical records without access to the original claims data. These audits are typically performed by coding vendors hired by health plans to look for “missed” diagnosis codes.

Since, first posing the question, “Could retrospective chart reviews be considered Medicare Fraud?” in a June 2013 blog post, I have been an outspoken opponent of retrospective practices and have worked to promote prospective practices and frontline education.  

Whether you agree or disagree with my views, everyone in risk adjustment should be paying very close attention to the upcoming trial set for July 24, 2017 in the Graves vs Plaza Medical Centers case.

In her 5th Amended complaint, Dr. Olivia Graves claims that Dr. Cavanaugh and PMC intentionally submitted erroneous diagnoses codes on Medicare Advantage patients for the sole purpose of increasing their MRA scores and subsequently increasing their capitation payments.

Dr. Graves also contends that Humana “turned a blind eye” to the fraud and did nothing to correct the problem after repeated internal audits showed high error rates. She further contends that none of their “risk adjustment data validation” processes were designed to detect fraud, but instead to capture additional codes for the sole purpose of increasing capitation payments.

On January 17th the court denied summary judgement and found material issues of fact relating to compliance activities, certification of risk adjustment data and the retention of overpayments.

Key Points from the Court’s Report and Recommendation

§  The undersigned finds that evidence in the record that raises genuine issues of material fact as to whether the shortcomings of the design and application of Humana’s compliance program met the CMS regulations or constituted reckless disregard.

§  The relator argues that “ample evidence supporting scienter falls into two primary categories: (1) Humana’s failure to make ‘good faith efforts’ to certify the accuracy of its data submissions and maintain an ‘effective compliance program’ as required by law; and (2) the red flags that Humana ignored at the time and continues to ignore in its Motion.”

§  The relator argues that neither of Humana’s two forms of oversight related to the submission of risk adjustment data—the Medicare Risk Adjustment (“MRA”) Review and Provider Data Validation (“PDV”) Review—were designed to detect fraud or upcoding, and were therefore incapable of satisfying Humana’s obligations to make “good faith efforts” to certify the accuracy of the data to which it was attesting and maintain an “effective compliance program.”

§  The relator argues that Humana’s MRA Reviews did not detect International Classification of Diseases 9 codes (“ICD9 codes”) that were unsupported or likely to be unsupported by the medical record, but instead were designed to identify diagnostic codes for submission to CMS that providers may have overlooked.

§  The relator argues further that such one-way reviews are compelling evidence from which a reasonable jury could conclude that Humana did not make “good faith efforts” to certify the accuracy of its risk adjustment data and did not have an “effective compliance system.”

§  The relator offers evidence that the MRA Review was designed to identify diagnostic codes for submission to CMS that providers may have overlooked. Using algorithms to identify specific patients with potentially unreported conditions, the relator argues that the goal of Humana’s MRA reviews was to increase the capitated payment received by Humana and its providers

§  Rather than reviewing a patient’s lab tests, specialist reports, and underlying medical records, Humana’s PDV reviewers relied solely on a physician’s progress notes to confirm diagnosis; for chronic conditions, they validated the condition so long as its corresponding ICD-9 code appeared in the progress notes, even if those notes did not identify any confirming evidence or treatment plans for the diagnosed condition.

§  The evidence in the record raises genuine issues of material fact as to whether the false submissions that Humana made to CMS based on Plaza Medical Centers and Dr. Cavanaugh constituted reckless disregard under the FCA.

§  Humana contends that “effective” and “good faith” are ambiguous terms and that the relator fails to cite any CMS guidance regarding their definitions let alone warn Humana away from its interpretation of the governing regulations.

§  The relator relies on the CMS regulations found in 42 C.F.R. § 422.504(l)(2) and 42 C.F.R. § 422.503(b)(4)(vi)) that respectively require an MAO like Humana 1) make good faith efforts to certify the accuracy of its data submissions, and 2) maintain an effective compliance program.  Additionally, the relator relies on the Ninth Circuit’s Swoben decision that rejected the defendant’s arguments that the CMS regulations were ambiguous and that the defendant’s interpretation was objectively reasonable due to CMS’ clear, authoritative guidance that requires MAOs “to undertake ‘due diligence’ to ensure the accuracy, completeness and truthfulness of encounter data submitted to CMS.” Swoben, 832 F.3d at 1099 (citing Fidelity Fed. Sav. & Loan Ass’n v. de la Cuesta, 458 U.S. 141, 158 (1982)) “[A]mbiguity alone [does] not shield claimants from FCA liability.” 

§  CMS regulations obligated Humana to exercise “due diligence” and “good faith efforts” to certify the accuracy, completeness, and truthfulness of encounter data that Humana submitted to CMS.  The CMS requires that MAOs must implement a compliance program that detects and prevents fraud, waste and abuse.  The relator’s evidence presents a fact question as to whether Humana satisfied its CMS obligations or not which goes to the issue of whether Humana recklessly disregarded the falsity of the claims it submitted on behalf of its providers, Plaza Medical Centers and Dr. Cavanaugh.

§  Humana contends that “absent evidence that Humana was on notice of alleged fraud, allegations that Humana did not precisely follow its own compliance program—the existence of which negates a finding of the requisite scienter—do not establish the knowing submission or certification of allegedly false diagnosis codes in violation of the FCA.” Motion at 23.  The relator argues that if Humana’s position was true, the defendants could always avoid FCA liability simply by implementing a “compliance program,” no matter how ineffectual.  The relator’s expert avers that “[a]lthough minor lapses in policy may be excused, the record evidence here indicates systematic failure to adhere to internal policies, rendering these policies entirely ineffective as … fraud detection measures.” Anderson Declaration at ¶ 140 (DE# 663-1).

§  The relator relies upon the Ninth Circuit’s decision in United States ex rel. Swoben v. United Healthcare Ins. Co., 832 F.3d 1084, 1098-99 (9th Cir. 2016), amended   F.3d, 2016 WL 7378731 (9th Cir. December 16, 2016), which held that the CMS guidance is (a) “authoritative” because “it provided clear guidance to [MAOs] … regarding their obligations under [42 C.F.R.] § 422.504(l);” (b) created an affirmative obligation to “undertake ‘due diligence’ to ensure the accuracy, completeness, and truthfulness of encounter data [i.e. risk adjustment data] submitted to [CMS];” and (c) imposed an affirmative obligation to make “good faith efforts to certify the accuracy, completeness and truthfulness of encounter data submitted.” Id. (citing 65 Fed. Reg. 40,248 (guidance preamble) (emphasis in original)).  MAOs are also required to “implement an effective compliance program, which must include measures that … prevent, detect, and correct fraud, waste, and abuse.” 42 C.F.R. § 422.503(b)(4)(vi).  In Swoben, the Ninth Circuit vacated and reversed the district court’s dismissal of Swoben’s third amended complaint without leave to amend.  The Ninth Circuit found that Swoben’s theory – “that the defendants designed their retrospective review procedures to not reveal unsupported diagnosis codes, allegedly for no other reason than to avoid reporting that information to the government-- states a cognizable legal theory under the False Claims Act.” 

§  The undersigned finds that the record evidence presents genuine issues of material fact for a jury to determine whether the relator can prove that Humana had the requisite scienter, that is “reckless disregard,” for FCA liability and whether Humana failed to undertake measures constituting a “good faith effort” to certify the truth and accuracy of its submissions to CMS and to maintain an effective compliance plan to detect and correct fraud.  Because there is sufficient evidence in the record upon which a reasonable jury could find for the non-moving party, the relator, this Court should deny Humana’s motion for summary judgment.

§  The reverse false claims provision imposes liability on anyone who “knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to the Government.”

§  The Patient Protection and Affordable Care Act of 2010 (“ACA”) requires a person who receives an overpayment of Medicare or Medicaid funds to report and return the overpayment within 60 days of the date on which the overpayment was identified.

§  “[T]he sixty day clock begins ticking when the provider is put on notice of a potential overpayment, rather than the moment when an overpayment is conclusively ascertained, which is compatible with the legislative history of the FCA and the FERA.”

§  The 2014 CMS regulation implementing the 60-day provision of the ACA provides that an MAO “has identified an overpayment when [the entity] has determined, or should have determined through the exercise of reasonable diligence, that [it] has received an overpayment.”

§  “[R]easonable diligence” includes “proactive compliance activities … to monitor for receipt of payments.”

§  The relator acknowledges, as the United States did in its Amicus Brief (Dkt No. 68) in United States ex rel. Swoben v. United States Healthcare Insurance Co., No. 13-56746 (9th Cir. 2016), that “[a]lthough some of the conduct alleged here predates the enactment of the [ACA] and all of the conduct predates the promulgation of CMS’s implementing regulation, these statutory and regulatory overpayment provisions are instructive as to what Congress intended in enacting the reverse-false-claims provision.”

§  Humana disputes that it had knowledge of overpayments and/or knowingly failed to return them within 60 days from when they were identified.  Humana contends that its “voluntary cooperation with DOJ’s investigation of Relator’s allegations precludes a finding that Humana ‘knowingly concealed’ or ‘knowingly and improperly avoided’ the return of alleged overpayments.”

§  The relator contends that the evidence in the record presents a fact question as to whether Humana recklessly disregarded or deliberately ignored overpayments as early as 2010, that is before the complaint was unsealed, and improperly retained those funds until 2016.

§  The relator relies on Humana’s November 2010 PDV Review of Plaza Medical Centers which determined that 35% of the 178 audited diagnostic codes, all of which were previously submitted to CMS, were invalid. The relator argues that this audit alone revealed that Humana had received overpayment for some, if not all, of the 63 invalid diagnostic codes that Humana identified during the November 2010 audit.  Humana waited until February 2016 to submit code deletions for nearly all of those invalidated codes, rather than calculating the resulting overpayments and returning the funds to CMS as it was required to do to avoid liability under 31 U.S.C. § 3729(a)(1)(G).

§  The evidence in the record presents a fact question for a reasonable jury to determine whether Humana had knowledge of and knowingly retained overpayments for improper diagnostic codes that were submitted to CMS.  The relator contends that Humana’s MRA Reviews were similar to the one-sided reviews in Swoben that in practice only captured under-reporting errors that would identify additional diagnosis codes and lead to an increase in payments from CMS.  In Swoben, the Ninth Circuit explained that when an MAO designs reviews that either avoid or conceal over-reporting errors, a lack of diligence and an absence of good faith exist.  Swoben, 2016 WL 7378731, at *10.

§  Humana contends that its cooperation with the Department of Justice’s (“DOJ”) investigation of relator’s allegations absolves it from reverse false claim liability. Humana maintains that its lack of independent investigation into Plaza Medical Centers and Dr. Cavanaugh was justified because:  1) the government declined to intervene; and 2) neither CMS nor DOJ told Humana to investigate its overpayments. 

§  The relator argues that Humana’s duty to investigate is independent of the DOJ’s investigation.  See Crumb, 2016 WL 4480690, at *16 (denying defendants’ motion to dismiss in part because “even in 2014, when [defendants] knew the Government was conducting FCA investigations into [defendants’] alleged false claims … defendants ‘failed to take any corrective or repayment action’” and, by 2015, had only made partial payments).

§  The undersigned finds that genuine issues of material fact exist as to whether Humana is alternatively liable for its knowledge of overpayments and its failure to return the overpayments to the government.