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A new diagnosis: Munchausen syndrome by payor?

Anthem is under fire for allegedly overcharging CMS $3.4 million for exaggerating the severity of patient conditions, according to Modern Healthcare’s May 24 story.

We’ve heard of Munchausen syndrome by proxy, but Anthem’s latest billing snafu has us wondering if a new diagnosis is in order — Munchausen syndrome by payor.

A report by the Office of the Inspector General (OIG) at the department of Health and Human Services shines a light on health insurer Anthem’s widespread billing bloopers regarding its contract with the Centers for Medicare & Medicaid Services (CMS). It may go without saying, but these “errors” financially benefitted Anthem, not CMS.

For context: Anthem is paid by CMS to manage the care of Medicaid Advantage (MA) members. This includes billing CMS based on the patients’ diagnosis codes. The OIG’s study sample indicates that Anthem misrepresented the severity of multiple patients’ conditions over a two-year period, saying they were sicker than they really were. Here’s why this could happen: As a MA insurer, Anthem gets a base amount from CMS to cover the care of these patients. But Anthem gets bump-ups in payments for patients who are sicker or higher-risk. So, the sicker the patients are, the more money Anthem gets to provide their benefits. So, you can see what could happen, should an insurer get greedy and exaggerate how sick patients really are. And you can almost see how they might consider it a victimless crime, as long as nobody notices.

Well, OIG noticed. The result? OIG would like Anthem to give CMS back the $3.4 million it overcharged. In many ways, this is a familiar story of misconduct through miscoding. This is becoming somewhat of a trend, what with Cigna, Anthem, and Humana all recently getting their fingers burned from reaching too deep into the MA honeypot.

Naturally, with millions of dollars at stake, Anthem isn’t issuing a mea culpa. Instead, they’ve questioned the methodology of the OIG’s review. Meanwhile, if the government is following any of this, hi there! We’ve got a question for you: What steps are you taking to keep insurers’ coding practices in check? And for hospitals following this story, we’ve got a word of warning: if insurers have learned how to work the coding system to their financial benefit—and aren’t reflecting patients’ actual medical conditions—it will be important to hold them accountable and make sure they’re coding and paying accurately for the care you provide.

Original Article:

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