HCCs: Audits of Medicare Advantage Plans and a Coder’s Role

by Rose T. Dunn, MBA, RHIA, CPA, FACHE

Hitting the headlines recently was the federal audit finding Humana overcharged Medicare nearly $200M. Humana Inc.’s Medicare Advantage health plan for seniors in Florida improperly collected nearly $200 million in 2015 by overstating how sick some patients were. The audit of Humana occurred from February 2017 to August 2020.

Auditors found that the plan’s medical records did not support the hierarchical condition category (HCC) conditions claimed. According to an article by Fred Schulte published by NPR, auditors said Medicare overpaid Humana by $249,279 for the 200 patients whose medical charts were closely examined in the sample. Auditors used a technique called extrapolation to estimate the prevalence of such billing errors across the health plan. “As a result, we estimated that Humana received at least $197.7 million in net overpayments for 2015,” the audit states, adding that Humana’s policies to prevent these errors “were not always effective” and need improvement.

In our HCC Auditor’s course, we dissect the rules applied by the federal auditors when they audit the records of Medicare Advantage (MA) plan providers. The MA plan has responsibility for ensuring the HCCs submitted are valid throughout the term of care, not just when the plan is audited. In Humana’s case, this should have been on their radar. Isaac K. A. Thompson, a Humana MA provider, was indicted in 2015 for fraudulent coding from 1/2006 to 6/2013. It appears that Thompson intentionally falsely diagnosed 387 Medicare Advantage beneficiaries with ankylosing spondylitis. Unfortunately, Humana didn’t identify it, but rather a whistleblower raised the flag.

HCC coding professionals should be on the look-out for unusual trends in diagnosis reporting and always validate that the documentation supports the diagnoses that the provider has selected. Coding professionals know the coding rules and providers do not. Providers will welcome your guidance on proper selection of diagnosis codes. Optionally, let’s encourage our providers to get out of the coding business. Guide your providers in documentation requirements (chronicity, stage, specificity, etc.) and you do the coding.


HCC: Auditing in the Risk Adjustment Environment
Internal HCC auditors: get the essential information you need to ensure your organization receives proper reimbursement — and that codes and claims are supported by clinical documentation.

Learn what to look for and how to communicate your findings. Tips and techniques offered by nationally recognized HCC authority Rose T. Dunn! Learn more here.

About the Author

Rose Dunn
Rose Dunn is the Chief Operating Officer at First Class Solutions, Inc., a healthcare information management leader since 1988. Rose is the author of “The Revenue Integrity Manager’s Guidebook” available from the National Association of Healthcare Revenue Integrity and other books on Coding Management and Auditing from HCPro. She engaged herself in ICD-10 more than 10 years before it was implemented. She is assisting Libman Education in the development of an HCC educational program. Rose holds a BS and MBA from Saint Louis University.

One thought on “HCCs: Audits of Medicare Advantage Plans and a Coder’s Role

  1. mildred g bethea - May 5, 2021 at 8:39 pm

    Wow, this is such excellent timing. I’m currently in training for a contract role as HCC/IVA. Because it’s so new and I’ve been trying to further understand the IVA role, this truly clarifies the importance of my new role. Please help me to stay on top of my knowledge, thank you!


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