Fed’s Medicare Risk Adjustment Plan Brings Increased Billing Scrutiny

As we expected, the new Medicare Risk Adjustment Factor is bringing increased scrutiny by the Centers for Medicare and Medicaid Services (CMS). News came earlier this month that the hospital provider Humana is facing allegations on this front.

The trouble on the Medicare Risk Adjustment Factor front started when the feds noticed that the new provider reimbursement plan wasn’t saving the money they had projected. The government’s focus understandably then moved to figure out what was gobbling up their savings.

The feds’ suspicion is that providers are attesting that beneficiaries have a higher burden of illness than is actually the case. This summary does a good job explaining the whole situation.

The upshot for providers? Know that CMS is looking hard at the Medicare Risk Adjustment Factor and make sure your documentation fully supports your attestation regarding each patient’s burden of illness.