Risk Adjustment Diagnosis Audit Trail For Medicare Advantage Plans

PROBLEM: On 30 September 2023 the Cigna Group agreed to pay $172,294,350 to resolve False Claims Act allegations that it submitted inaccurate diagnosis codes for Medicare Advantage enrollees between 2014 and 2019 through a chart-review program and in-home assessments, in order to obtain extra payments from Medicare. Diagnosis codes added after the clinical encounter had no routine audit trail tying each code to corroborating clinical information.

SOLUTION: An IBM Cloud Ideas compliance audit trail that records every diagnosis code submitted for risk adjustment with its source document, the clinician record it rests on, whether it came from a chart review or an in-home assessment, and any later deletion, so unsupported codes are visible before submission.

EVIDENCE BASIS: DOCUMENTED — DOJ / U.S. Attorney's Office (E.D. Pa.), 30 September 2023: Cigna Group $172,294,350 False Claims Act settlement over alleged inaccurate Medicare Advantage diagnosis codes; $37 million component carried factual admissions; five-year Corporate Integrity Agreement with HHS-OIG.