The Tables Are Turning: OIG Sets Sights on Medicare Advantage DRG Validation Denials

DRG validation denials by Medicare Advantage (MA) plans have become a widespread and increasing concern for many hospitals.

But these denials may be the result of a misapplication of standard diagnostic criteria by a reviewer. Now, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) is turning the DRG validation denials back on MAs. The OIG recently published several diagnosis-validation audits of MAs and recommended recoupment for exactly the same diagnoses the MAs have denied for providers.

But what can we learn from these audits to help manage diagnosis denials by payers? Does this portend new MA tactics? Sitting in for Dr. Ronald Hirsch during the next edition of Monitor Mondays will be our own physician and attorney, Dr John K. Hall, who will offer his take on the future of diagnosis denials and how to prepare.

Other segments will include these instantly recognizable broadcast segments:

• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors;
• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment;
• SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH; and
• Legislative Update: Matthew Albright, chief legislative affairs officer for Zelis, will report on current healthcare legislation.