Articles
CMS Claims Risk Adjustment Overpayments Commonly Include 10 Specific DiseasesThere 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.
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 ...
