2015 Annual Training Conference & Anti-Fraud Expo

Sessions Speakers Exhibitors Show Specials Floor Plan Buzz

CANCELLED: Medicare Risk Adjustment Fraud (Room Coronado A)

18 Nov 15
9:15 AM - 10:15 AM

Tracks: Legal, Management & Compliance Issues, Management Path

Risk Adjustment fraud schemes are no longer just about selecting and enrolling healthy members (false enrollment schemes). False documentation practices can artificially inflate risk scores creating a different view of risk adjustment fraud schemes. The fraudulent practices may impact Medicare, Medicaid, and commercial lines of business. Because of this deviation from what is known to be typical, the presenters will explain this at a deeper level so participants can walk away with an overall increased knowledge base regarding risk adjustment fraud. The presenters will explain what risk adjustment is from a clinical and payment perspective. This will include discussion on diagnosis coding and hierarchical condition categories (HCC's) that drive the premium payments. The different HCC models that can be used will also be discussed. This information lays the foundation to understand the complexity of risk adjustment fraud schemes. The presenters will describe how frauds are being perpetrated. These are not simply upcoding of a condition but complex schemes that require analytical evaluation of coding practices and also include financial and medical record analysis. To further enhance comprehension of these schemes, the presenters will then walk through an actual case.