Monday, December 13, 2021

Key Litigation and Audits involving Risk Adjustment

If you work in risk adjustment - you should be familiar with these cases. 

  • On August 5, 2020, a whistleblower case filed by the Department of Justice was unsealed. The complaint accuses Cigna of fraudulently overbilling for its Medicare Advantage plans. A former service provider for Cigna’s Medicare Advantage subsidiary alleged that the company sent providers to patients’ homes to conduct a health assessment, which was then improperly submitted to the Centers for Medicare and Medicaid Services for risk adjustment. Allegations include claims the company submitted unsupported diagnoses that resulted in “billions” in overpayments. Litigation is ongoing - 7:17-cv-07515-KMK-JCM United States of America, EX REL. Robert A. Cutler v. Cigna Corp. et al.

  • On August 30, 2021, the government announced a $90 million False Claims Act settlement with California-based health care services provider Sutter Health.  The settlement resolves allegations that Sutter knowingly submitted inaccurate diagnosis codes for beneficiaries enrolled in Medicare Advantage Plans.  This inaccurate information led to inflated payments to Medicare Advantage Plans and Sutter Health.

  • On September 14, 2021, DOJ filed a Medicare Advantage fraud lawsuit against Independent Health and its former CEO.  Independent Health offers two Medicare Advantage Plans in New York State.  The United States has also sued Independent Health’s subsidiary, DxID.  DxID provided retrospective chart review and addenda services to Independent Health and other MA Plans. The case is captioned United States ex rel. Ross v. Independent Health Association et al., No. 12-CV-0299(S)

The BEST Risk Adjustment Education


Are you looking for the best education available in risk adjustment, value-based payments and/or CDI? Good News - You have found it!

Join us for a day of risk adjustment and get the BEST risk adjustment education available for $49. 

Do you need CMEs, CEs or CEUs? We have that too!

All Workshops are approved by the American Medical Association, American Academy of Family Practice, Commission for Case Manager Certification, and the American Academy of Professional Coders.

Register your team (3 or more) today to save 10% on any 2022 Workshops!

Upcoming dates: 

Learn more / Download the agenda here -

Workshops typically sell out 2 weeks or more before the event. 
Don't wait - register your team today!!

Wednesday, June 2, 2021

The BEST Risk Adjustment Workshop Available

Are you looking for the best risk adjustment education available? If so, GREAT NEWS, you found it! Join us virtually for a day of risk adjustment, CDI and HCC coding! NEW DATES added below:

June 25, 2021 – Register for tickets here

July 30, 2021 – Register for tickets here

August 27, 2021 – Register for tickets here

September 24, 2021 – Register for tickets here

APROVED by:  AMA, AAFP, AAPC and CCMC - Earn 7.0 CEUs, 6 CMEs and/or 5.5 CEs. - $49 per Attendee

Register your team today and save 10% with group discounts!


Friday, April 30, 2021

Advanced Risk Management and HCC Workshop

Are you looking for the best risk adjustment education available? If so, GREAT NEWS, you found it! Join us virtually for a day of risk adjustment, CDI and HCC coding! NEW DATES added below:

June 25, 2021 – Register for tickets here

July 30, 2021 – Register for tickets here

August 27, 2021 – Register for tickets here

September 24, 2021 – Register for tickets here

APROVED by:  AMA, AAFP, AAPC and CCMC - Earn 7.0 CEUs, 6 CMEs and/or 5.5 CEs. - $49 per Attendee

Register your team today and save 10% with group discounts!


Wednesday, April 21, 2021

Medicare Advantage Compliance Audit of Diagnosis Codes That Humana Submitted to CMS

Why OIG Did This Audit

Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services (CMS) makes monthly payments to MA organizations according to a system of risk adjustment that depends on the health status of each enrollee. Accordingly, MA organizations are paid more for providing benefits to enrollees with diagnoses associated with more intensive use of health care resources than to healthier enrollees who would be expected to require fewer health care resources.

To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS. CMS then maps certain diagnosis codes, on the basis of similar clinical characteristics and severity and cost implications, into Hierarchical Condition Categories (HCCs). CMS makes higher payments for enrollees who receive diagnoses that map to HCCs.

For this audit, we reviewed one of the contracts that Humana, Inc., has with CMS with respect to the diagnosis codes that Humana submitted to CMS. Our objective was to determine whether Humana submitted diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements.

How OIG Did This Audit

We selected a sample of 200 enrollees with at least 1 diagnosis code that mapped to an HCC for 2015. Humana provided medical records as support for 1,525 HCCs associated with the 200 enrollees. We used an independent medical review contractor to determine whether the diagnosis codes complied with Federal requirements.

What OIG Found

Humana did not submit some diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements. First, although most of the diagnosis codes that Humana submitted were supported in the medical records and therefore validated 1,322 of the 1,525 sampled enrollees' HCCs, the remaining 203 HCCs were not validated and resulted in overpayments. These 203 unvalidated HCCs included 20 HCCs for which we identified 22 other, replacement HCCs for more and less severe manifestations of the diseases. Second, there were an additional 15 HCCs for which the medical records supported diagnosis codes that Humana should have submitted to CMS but did not.

Thus, the risk scores for the 200 sampled enrollees should not have been based on the 1,525 HCCs. Rather, the risk scores should have been based on 1,359 HCCs (1,322 validated HCCs + 22 other HCCs + 15 additional HCCs). As a result, we estimated that Humana received at least $197.7 million in net overpayments for 2015. These errors occurred because Humana's policies and procedures to prevent, detect, and correct noncompliance with CMS's program requirements, as mandated by Federal regulations, were not always effective.

What OIG Recommends and Humana's Comments

We recommend that Humana refund to the Federal Government the $197.7 million of net overpayments and enhance its policies and procedures to prevent, detect, and correct noncompliance with Federal requirements for diagnosis codes that are used to calculate risk-adjusted payments.

Humana disagreed with our findings and with both of our recommendations. Humana provided additional medical record documentation which, Humana said, substantiated specific HCCs. Humana also questioned our audit and statistical sampling methodologies and said that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program. After reviewing Humana's comments and the additional information that it provided, we revised the number of unvalidated HCCs for this final report. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program. We revised the amount in our first recommendation from $263.1 million (in our draft report) to $197.7 million but made no change to our second recommendation.

Complete Report available here. 


Friday, April 2, 2021

Medicare Risk Adjustment Operations


Medicare Risk Adjustment Operations

On-Demand Course Overview:

Medicare Advantage (MA) is one of the fastest-growing and most complex health plan lines of business representing significant growth opportunities for payers. Launching and/or managing a successful MA market requires careful, strategic planning to meet requirements, ensure compliance, and maximize the program benefits for your organization.

Success in this market will depend on success in each of the following essential areas:

  • Value-based contracting
  • Clinical documentation and coding
  • Delivering high quality care
  • Managing utilization

This course will touch on all four essential areas of MRA Operations.

APPROVED by the AAPC for 5 CEUs - $9.99 until 4/9/2021 and then $19.99

Register here

Learn more about ERM365

Saturday, March 20, 2021

Let's Talk About Risk

 Approved by the AAPC for 2 CEUs  - $5.99 (on SALE until 3/25/2021 - then $14.99)

Review the Agenda:

Section 1 – Risk Adjustment Basics

This section will cover basic concepts and terminology in the CMS-HCC Model of Risk Adjustment.

  • What is an HCC?
  • Why are HCCs important?
  • How is a risk score calculated?
  • What is the value of an HCC?
  • What are the most common HCCs?

Section 2 – Rules of the Road

This section will cover ICD-10 Guidelines and other “rules” related to clinical documentation and coding within the CMS-HCC Model of Risk Adjustment.

  • When should a diagnosis be coded?
  • How often can a diagnosis be coded
  • What clinical documentation is needed to support the diagnosis?
  • Is it okay to code for resolved conditions?
  • Would it be acceptable to code a diagnosis documented as “suspected” in an outpatient setting such as a provider’s office?

Section 3 – HCC Coding

This section will review the most common HCC’s for Medicare enrollees based on MedPAC data.

  • What are the twenty most common HCC categories for Medicare enrollees?
  • What are the most common ICD-10 codes included in each category?
  • How can clinical documentation impact code selection?
  • What are common errors leading to inaccurate risk scores?

Section 4 – Tips for Success

This section will cover simple tips that will make a big impact. At the end of this lesson you will be able to work smarter not harder.

  • What should be included in the problem list?
  • Why does clinical documentation need to clarify active vs. history of?
  • What small changes can you start making today that will have a big impact on the accuracy of your risk scores?


Who Should Attend? 

  • Coders, Billers, and Auditors
  • Physicians, NPs and PAs
  • Medical Assistants and Front Office
Price: $5.99 SALE until 3/25/2021, then $14.99 
  • Purchase includes a copy of the presentation and other resources. 
  • 180 days of access to course and materials. 


On Demand Course Instructions for CEUs:

  1. Login or Register for a FREE account with ERM365.
  2. Purchase the course.
  3. Click on “My Dashboard” and then “My Courses” to access.
  4. Download the handouts and other resources.
  5. Watch the video.
  6. Pass the post quiz.
  7. Download CEU Certificate. 

Friday, March 19, 2021

Master E/M Coding 2021

E/M Changes Took Effect January 2021

As of January 1, 2021, physicians will select an E/M code based on total time spent on the date of the encounter or medical decision making (MDM)—whichever is most financially advantageous. 

What was the Goal of Revising the E/M Coding for Office Visits?

  • To decrease the administrative burden of documentation and coding
  • To decrease the need for audits, through the addition and expansion of key definitions and guidelines
  • To decrease unnecessary documentation in the medical record that may not be pertinent to the patient’s care
  • To ensure that payment for E/M is resource-based and that there is no direct goal for payment redistribution between specialties

On-Demand Course Agenda

Approved by the AAPC for 3 hours of CEUs - $6.99

Lesson 1 – Introduction

Lesson 2 – 2021 E/M Guidelines and Key Terms
  • Guidelines Common to all E/M Services
  • Services Reported Separately
  • Guidelines for Office or Other Outpatient Services
  • MDM Element Definitions

Lesson 3 – Selecting the Level of E/M Services
  • Instructions
  • New Patient Codes
  • Established Patient Codes

Lesson 4 – Prolonged Services
  • Without Direct Patient Contact
  • Prolonged Clinical Staff Services

Lesson 5 – Frequently Asked Questions

  1. Register for a FREE account on ERM365 (if you do not already have one)
  2. Register for the course 
  3. Complete the lessons
  4. Pass the post test
  5. Print your CEU certificate

View more courses on ERM365

Friday, March 12, 2021

Advanced Risk Management and HCC Coding for Value Based Payments On-Demand


Advanced Risk Management and HCC Coding for Value Based Payments On-Demand

Join us on-demand for this event recorded on 11/13/2020. This course is an advanced course on risk adjustment and HCC coding for coders, physicians and other healthcare professionals.

Approved by the AAFP and AMA for 5 CMEs and the AAPC for 7 hours CEUs – only $49.00


  • Vast changes are coming to Medicare risk adjustment in 2021 and beyond. Is your team ready? What are the potential impacts to your revenue?
  • Discuss the importance of managing HCCs year over year. What resources are available from CMS to help?
  • What are the components of a risk score and how is it calculated? What is the impact of the payment count?
  • Review NEW HCCs and see what documentation is needed to validate payment.
  • Simple steps for optimizing risk adjustment operations and associated revenue.
  • Take a deep dive into the grey areas and red flags of HCC coding and clinical documentation. See what your team should and should not be coding. 


  • Physicians and Other Providers
  • Coders, CDI Specialists and Auditors
  • Nurses, Medical Assistants and Scribes
  • Medical Directors and CIOs
  • MA, Medicaid and Commercial Plans
  • ACO, MSO and IPA Teams
  • Hospitals and Academic Centers
  • Community Health, RHCs and FQHCs
  • Health Alliance Members

PRICE: $49

On Demand Course Instructions for CEUs:

  1. Purchase the course 
  2. Download the handouts
  3. Watch the video
  4. Pass the post test
  5. Download CEU Certificate
  6. Submit post course survey

Would you prefer to attend a LIVE event? We have several upcoming LIVE events - view the schedule and/or register here

Wednesday, March 10, 2021

2021 CMS-HCC Coding Books and Tools


Is Your Team Risk Ready?

Arm Your Team For Combat This Risk Adjustment Season!

Prepare for Victory...

What will define those who claim victory and those who are defeated in the battle towards value based care? Will it be those organizations with the most money, power and seats at the table? Or will it be those who are nimble, flexible and open to change?

I believe it will be both. As victory will not be defined by the owners and head coaches but instead by how the players execute on the field. It will be the game time decisions that matter most. A quarterback who can read the defense and adjust accordingly will provide far greater value to the offense than the most athletic quarterback who misses the blitz every time.

Perhaps Napoleon said it best, "Battles are won by the power of the mind." For in a game of inches, the winners and losers will be defined by those who can execute in the moments that matter most. Prepare your team for victory with information at the point of care!

Learn more / order here -

Creating Value in Health Care


APPROVED by the AAPC for 4 CEUs - $12.99

On-Demand Course Overview:

We insist on value when we buy our lunch, our car, our clothes, and our home. Why not in healthcare?

Since 2015, the US has been transitioning from a fee-for-service payment system to one based on value. This on-demand course will introduce the concepts of value-based care, population health and social determinants of health with highlights from Dr. Hart’s new book, “Value in Health Care”. By active creation of value in healthcare, we can rein in costs while improving quality outcomes and the experience of patients and providers. 

A journey toward sustainable healthcare with improved results.

“When we identify individual-level social risk factors, we can devise interventions to address them specifically or collect data to understand where community-level interventions might improve a population’s health.”

— Jon Hart, MD MBA

Course Instructions 

  1. Register today and complete at your own pace. 
  2. Complete the course. 
  3. Pass the post test. 
  4. Download your certificate. 

Link to Register

View more courses on ERM365

Saturday, February 20, 2021

Opioid Use Disorder


Opioid Use Disorder is defined by the DSM-5 as a “problematic pattern of opioid use…”

  • A code of F11.20, opioid dependence, should not be assigned for patients taking pain medication as prescribed.
  • Instead a code of Z79.891, long term use of opiates, should be assigned.

Coders should always be mindful of ICD-10 Guidelines and Coding Clinic Guidance when assigning codes for substance use disorder.

2021 ICD-10 Guidelines (pages 43-44)

Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)

b. Mental and behavioral disorders due to psychoactive substance use

3. Psychoactive Substance Use, Unspecified
As with all other unspecified diagnoses, the codes for unspecified psychoactive substance use (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-, F18.9-, F19.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). These codes are to be used only when the psychoactive substance use is associated with a physical disorder included in chapter 5 (such as sexual dysfunction and sleep disorder), or a mental or behavioral disorder, and such a relationship is documented by the provider.

AHA Coding Clinic Guidance

Medical record documentation indicates the patient is taking opioids prescribed by their physician for treatment of chronic pain. Does Guideline I.C.5.b.3. mean that codes cannot be assigned for the opioid use unless there is documentation of an associated physical, mental or behavioral disorder?

A code for the use of prescription opiates would not be reported because there is no associated physical, mental or behavioral disorder.

Reference: AHA Coding Clinic 2018 2nd Quarter, pages 11 and 12

Learn more or download a copy of DSM-5 Criteria here