ArticlesYes, You Have What It Takes To Lead Your Practice And Your Profession
If you’ve been in any healthcare role for more than two years, you’ve seen quite a bit of change. And guess what, it’s not over. We are living and working in uncertain times. This climate requires each of us to step outside of our comfort zones to lead exactly where we stand. It’s not required of one to have a “title” to lead. What is required, however, is a willingness to trust your instincts, look for answers and rely on your team.
Are You Prepared to Avoid Repayments
Watchful care is needed when submitting claims. The Office of the Inspector General (OIG), after completing an audit on a Medicare Advantage Plan in August 2022, is now demanding repayment of claims to the tune of $3,518,465. Although the payer is contesting that amount, it is possible that they may begin demanding repayments from the providers to cover their costs of repayment.
Calendar Year 2023 Medicare Advantage and Part C & D Payment Policies
Each year CMS publishes an Advance Notice of the upcoming years Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and asks for comments related to it. Each of the comments are carefully reviewed and responded to and often are impactful to changes seen between the Advance Notice and final publication referred to as the Rate Announcement. With health equity as a primary focus for 2023, CMS announced some policy changes that may impact your organization.
OIG Investigates SCAN Health for Risk Adjustment Overpayments With Surprising Results
We’ve seen a number of OIG risk adjustment data validation (RADV) audits recently where the independent review contractor was simply looking for any codes the payer reported that were not supported by the documentation, in an effort to declare an overpayment was made and monies are due to be repaid. However, it was refreshing to read this RADV audit and discover that the independent review contractor actually identified HCCs the payer failed to report that, while still resulting in an overpayment, was able to reduce the overpayment by giving credit for these additional HCCs. What lessons are you learning from reading these RADV audit reports?
Medicare Advantage (MA) Benchmarking Policies Are Headed for Change
More than 43% of Medicare beneficiaries are not enrolled in Medicare Advantage plans, which were established to control costs and improve quality. However, as noted in the March MedPac Report Executive Summary of 2021, these plans average an estimated 104% of Medicare Fee-For-Service (FFS) spending. How does CMS plan to manage Medicare Advantage plans now?
Sometimes it's the Little Coding Conundrums That Keep Us Concerned
We all experience coding situations that make us stop and rethink our coding path. Do we have the most current information on this situation? Does the payer contract change the way we must report the service? Are we missing something? Each of us experience simple to complex coding issues in our work and sometimes it is just nice to collaborate and discuss them openly to see how they may be resolved. Have you ever questioned the proper use of major depressive disorder codes versus the newly added (2021) depression, unspecified code? Take a look at what the OIG said about these codes and how the payer responded.
How Extensions to the COVID-19 Public Health Emergency Affect Healthcare Reimbursement
Providers need to begin preparations for how to handle a return to pre-COVID-19 public health emergency (PHE) policies. As the saying goes, "you can't put the rabbit back in the hat." Some COVID-19 PHE policies are so well liked it will be very difficult for the government to return to pre-COVID-19 policies. For now, we have at least the promise of a 60-day notice to all governors precipitating the end of the PHE.
Do You Know What Code is Used to Report Long-Haul COVID-19 Conditions?
A new code was added to the ICD-10-CM official code set with an effective date of October 1, 2022 for reporting post-COVID-19 sequela. We have all heard about people having odd conditions following COVID-19, well now there is a code available for reporting all of these anomalies, but are you familiar with the code and the rules for reporting it?
CMS Claims Risk Adjustment Overpayments Commonly Include 10 Specific Diseases
There are many lessons that can be learned from a single OIG audit report. In this recently-published OIG report, several of the most common documentation and coding errors are pointed out in relation to reporting HCCs for risk adjusted plans. Take a few minutes to review the report and see if improvements within your own organization can be made from what you learn.
How Would Your Organization Defend This Auditing Accusation?
The Office of Inspector General (OIG) is always working on audits in a pursuit of accurate reporting and reimbursement. A recently published OIG audit report can provide great information on how to protect providers and risk adjustment payers from serious financial losses by showing exactly what the OIG is looking for and how the payer (or provider) may have defended their coding choices. In this article, you will see how the OIG audited the HCC for major depressive disorder and what Anthem did to defend its reporting.
Opportunities to Identify Risk Adjustable Chronic Conditions Expands in 2022
Medicare made changes to the rules governing concurrently reporting transitional care management services and chronic care management services during the same calendar month. How might this help providers identify chronic conditions that risk adjust?
Medicare FFS Beneficiaries Average 2 or More Chronic Conditions
Medicare Advantage plans were created in an effort to improve patient health outcomes, quality of healthcare services, and reduce costs by managing chronic health conditions better than traditional Medicare plans. According to a CMS-published report from 2018, the average Medicare FFS beneficiary suffers from at least two chronic health conditions with a per capita cost of $2,067. Can you guess how many suffer from six or more chronic conditions?
ESRD Hemodialysis Hits Home with the New ETC Model
In 2021, two major ESRD programs became effective, essentially preparing to transform not only risk adjusted services, but also at-home dialysis, health equity among beneficiaries needing transplant services, and improved access to donor kidneys.
Take-Aways from the Medicare Part C and the Star Ratings 2023 Advanced Notice of Changes
Each year changes are made in many facets of risk adjustment calculations and processes. For the upcoming calendar year 2023, there are many changes coming, including announcements about the potential for risk-adjusting social determinants of health (SDoH) codes. A summary of some of the most significant changes are included for your review.
Are Risk Adjusted Plans Getting a Makeover?
The Centers for Medicare and Medicaid Services Innovation Center (CMMI) is responsible for developing, implementing, and evaluating the risks associated with healthcare payment models such as Medicare Advantage (a risk adjustment payment model). Recent investigation outcomes have shown payers are consistently reporting services not supported by documentation in an effort to increase revenue. As such, big changes to the CMMI health care payment models, including risk adjusted models, may be headed our way in 2023.
SDoH Improves Reimbursement and Risk Scores
The new guidelines for evaluation and management (E/M) services 99202-99215 refer to social determinants of health (SDoH) on the new or revised Table of Risk. Healthcare professionals have long hoped for the ability to score these problematic patient conditions in a meaningful way, not only for reimbursement, but also for quality of care and treatment options. SDoH codes recently added to the ICD-10-CM codeset continue to impress upon us the importance of identifying and reporting these patient issues and when combined with the new table of risk for scoring the E/M service, can impact reimbursement and care.
Medicare End-Stage Renal Disease (ESRD) Beneficiaries Rush to Join Medicare Advantage
SUMMARY: Medicare Advantage plans saw a surge in enrollments as ESRD Medicare beneficiaries were permitted to enroll in Medicare Advantage plans for the first time in 2021. Will your organization be ready for ESRD audits?
Monitoring Surgical Patients for VTE May Result in Higher RAFs
A news release published in the American Association for the Advancement of Science (AAAS) included findings of a global surgery study identifying patients with either a current, recent, or previous COVID-19 infection have up to a five-times increased risk of death from venous thromboembolism (VTE) when undergoing a surgical procedure.
Lessons Learned from an RADV Audit Report
If given an opportunity to know ahead of time the questions that would be asked of you in an upcoming interview or quiz, it is likely the outcome would be significantly better than if you were surprised by the questions. This same concept may be applied to audits of risk ...
How Well Will Your Organization Score in the 2022 Star Rating Measures?
How ready is your organization for implementation of the 2022 new Star Rating measures? Creating opportunities for staff to share innovative ideas is essential to creating a successful outcome, so take a minute to review the Part C and D measures today.
Is Coding Based on Addendums or Late Entries Putting You At Risk of Audit Failure?
Independent Health, another Medicare Advantage Organization, has been named in a qui tam (whistleblower) lawsuit and enjoined by the DOJ for allegations of fraudulently upcoding to increase beneficiary risk adjustment scores to obtain higher reimbursement. It appears they used DxID, LLC, a coding consulting subsidiary of Independent Health to retrospectively identify and have providers addend unsupported diagnoses. How is your organization actively protecting against accusations of upcoding by improper use and reporting of diagnoses from provider addenda?
Medicare Advantage - The Fastest Growing Government-Funded Program Undergoing Multiple Fraud Investigations
Medicare Advantage is the fastest growing form of government-funded healthcare and the rate of fraud within this segment has come under increased scrutiny. Funding is determined by the health status of each beneficiary; therefore, accurate coding based on detailed documentation makes the medical record vital to the process because some ...
How Does Global and Professional Direct Contracting (GPDC) Affect Risk Adjustment?
CMS recently announced the 53 Direct Contracting Entities (DCEs) that will be participating in the April 1, 2021 through December 31, 2021 Global and Professional Direct Contracting (GPDC) Model. Among those participating is Clover Health Partners, who runs an in-home primary care program that has the potential to help Medicare ...
Managed Care Organizations Use CMS Tools to Identify Outliers
Managed Care Organizations (MCOs) include risk-adjusted plans whose funding is based on the health status of their beneficiaries. Government-funded MCOs use CMS information to search for suspected cases of fraud and abuse.
OIG Plans for Onslaught of Risk Adjustment Audits Claiming 9.5% Error Rate in Code Assignment
As the OIG has published their intent to further investigate the 9.5% of improper payments based on incorrect ICD-10-CM code assignation, they implore Managed Care Organizations (MCOs) to begin employing some of the CMS tools and data analytic programs used to help identify outliers.
Identifying Risk-Adjusted Services During the Opioid Crisis
Between June 2019 and June 2020, the United States saw a total of 107,750 deaths from COVID-19. The spread of this virus was so extraordinary that it led President Trump to declare a public health emergency, and we watched as individual states began implementing laws and regulations to limit social interaction ...
How to Combat COVID-Related Risk Adjustment Losses with the Medicare Annual Wellness Exam
Identifying new ways to encourage Medicare beneficiaries to schedule and attend their Annual Wellness Exam (AWE) can be difficult, but the Open Enrollment period is a prime time for every payer to identify new beneficiaries and provide a reminder to both new and existing patients that this preventive service does ...
How Social Determinants of Health (SDOH) Data Enhances Risk Adjustment
The role of SDOH in overall patient care and outcomes has become a more common topic of discussion among healthcare providers, payers, and policymakers alike. All are attempting to identify and collect SDOH and correlate the data to patient management which is increasingly seen as necessary to address certain health disparities and identify exactly how SDOH affects patient health outcomes. Learn how to address this important subject.
How Reporting E/M Based on Time May Lose Money
Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's ...