News to Note – June 2025

• There is an ongoing criminal investigation into United Healthcare’s Medicare Advantage activities. We have all seen the multitude of audits that found that Medicare Advantage plan reporting of Hierarchal Condition Categories is problematic, and this seems like a possible target, but I would think to make this criminal there must be evidence that this was systematic and intentional.
• HCC issues with MA plans: The plans do everything possible to maximize their enrollee’s risk score to maximize their payment from CMS. When an MA patient is seen, the provider sends the claim with all the diagnosis codes to the MA plan but also sends a second claim to CMS to get paid the added payments for medical education and uncompensated care. But the way CMS gets the diagnosis codes to calculate risk scores is different. The MA plans separately submit information to CMS via the Encounter Data Processing System. 
• If you submit a claim to an MA plan for an admission and they come back and do a clinical validation audit weeks, months, or even years later and remove a diagnosis, usually downgrading the DRG and demanding a refund, they are obligated to also submit a correction to the Encounter Data Processing System retracting that diagnosis and refund any payment they may have received.
• It is critically important that doctors use the right terminology for diseases so that the quality of care hospitals provide can be accurately measured. Addressing a commonly debated diagnosis, sepsis, we now have an official government agency telling us how they define sepsis. The Government Accountability Office, which audits every facet of government including spending, in their audit of the quality of the medical care provided at Department of Defense facilities defines sepsis as requiring organ dysfunction. However, the GAO is not CMS. The adherents of SIRS will still claim they can code sepsis even though the patient never developed organ dysfunction. But many of us will still see SIRS as a warning sign that the patient is at risk of developing sepsis and that the fast action of the medical team prevented sepsis so alas all that can be coded is the infection.