CRC Compliance & Regulatory Requirements 2 — Questions and Answers
Question 1: Under the 60-Day Overpayment Rule, when does the 60-day clock begin for an MA plan discovering risk adjustment overpayments?
- When the chart audit is completed
- When the plan first identifies or should have identified the overpayment through reasonable diligence (Correct answer)
- When CMS notifies through a RADV audit
- 60 days from calendar year end
Correct answer: When the plan first identifies or should have identified the overpayment through reasonable diligence
The clock starts when the overpayment is identified or should have been identified. Plans cannot delay audits to delay the clock.
The 6-year lookback period means overpayments up to 6 years old must be returned if identified.
Question 2: An MA plan contracts with a vendor for retrospective chart reviews. Which OIG compliance concern is most relevant?
- Anti-Kickback Statute
- Prohibition on upcoding if the vendor is incentivized to find diagnoses regardless of support (Correct answer)
- Stark Law referral relationships
- HIPAA privacy rules only
Correct answer: Prohibition on upcoding if the vendor is incentivized to find diagnoses regardless of support
Chart review vendors paid to find HCC gaps have an inherent incentive to add diagnoses that may not be fully supported.
OIG has identified vendor compensation tied to HCC findings as a major risk factor. Plans remain responsible for all submitted data.
Question 3: Which regulatory body has primary authority over Medicare Advantage risk adjustment compliance?
- State insurance departments
- CMS through its Center for Program Integrity (Correct answer)
- The Department of Justice exclusively
- AHIP as industry self-regulatory body
Correct answer: CMS through its Center for Program Integrity
CMS/CPI administers RADV, sets data submission requirements, and enforces compliance. DOJ may pursue FCA cases, but CMS is primary.
Enforcement involves CMS, OIG, DOJ, and qui tam whistleblowers. Compliance failures can trigger actions from multiple agencies.
Question 4: A provider's documentation consistently uses copy-forward, resulting in identical problem lists across encounters. What compliance concern does this raise?
- No concern, copy-forward is an accepted EHR feature
- Significant concern that diagnoses may be perpetuated without active clinical assessment (Correct answer)
- Minor concern only if content contains errors
- Concern only if the provider bills at higher E/M levels
Correct answer: Significant concern that diagnoses may be perpetuated without active clinical assessment
Diagnoses may be perpetuated without the provider actively assessing whether each condition is still present and relevant.
RADV auditors seeing identical notes across encounters will question whether any encounter represents a genuine assessment.
Question 5: What is the minimum coding intensity adjustment CMS applies to MA risk adjustment payments?
- 10% reduction for plans below 3.0 Stars
- A mandatory 5.91% reduction to all MA risk scores to account for MA-FFS coding differences (Correct answer)
- A variable adjustment based on individual audit results
- An increase for dual-eligible populations
Correct answer: A mandatory 5.91% reduction to all MA risk scores to account for MA-FFS coding differences
The 5.91% reduction accounts for the documented fact that MA plans capture more diagnoses than FFS Medicare.
This adjustment is mandated by the ACA and represents a floor. Inaccurate coding compounds the financial impact since plans already receive reduced payments.
Question 6: An MA plan receives a qui tam complaint alleging risk adjustment fraud. What protections does the whistleblower have?
- No protections
- Protection from retaliation, 15-30% of government recovery, and right to participate in proceedings (Correct answer)
- Automatic immunity from personal liability
- Protection only if currently employed
Correct answer: Protection from retaliation, 15-30% of government recovery, and right to participate in proceedings
The FCA provides anti-retaliation protection, a financial share of recovery, and the right to participate in litigation.
Recent years have seen significant MA risk adjustment qui tam cases with recoveries exceeding $100M.
CRC Compliance & Regulatory Requirements 2
Under the 60-Day Overpayment Rule, when does the 60-day clock begin for an MA plan discovering risk adjustment overpayments?