Electronic Health Reporter

The CMS (Centers for Medicare and Medicaid Services) employs HCC (Hierarchical Condition Category) for determining payment level for Medicare Advantage Plans. The difference in diagnosis of patients and outcome of their health makes for the risk- adjusted payment. Patients suffering multiple chronic conditions are prone to greater risk scores. For physicians practice accurate HCC coding becomes an important element for managing the revenue cycle.

These risk scores are derived by HCC which are annually assigned to the members. HCCs are completely based on claims data which is collected from the providers. This information further gets annually validated through an audit, which is referred as RADV audit (risk adjustment data validation).

For tackling this situation in a better manner, many payers have started education initiatives for guiding their medical staff and physicians to document complete and accurate medical records. Your medical records determine risk scores of all the members. Here we will tell you how professional support can be a holistic approach for reaping greatest benefits and further  upgrading your HCC revenue cycle management:

Let’s begin with have a brief insight into HCC codes:

Under HCC codes, your reimbursement depends on diagnosis of the patients. The risk score is higher with the patient having severe diagnosis. HCC codes are also referred as “payment multipliers” by CMS. All the guidelines are to choose a primary diagnosis under risk adjustment.

• Describing the main reason for the encounter.
• Adding codes which describes coexisting conditions.

Now, let’s start with the importance of professional support in order to upgrade our HCC Revenue Cycle Management:

1. Staying Updated with Guidelines

We recommend you to look for a partner who have expertise working in the HCC risk adjustment, encounter data submission, preparation of audits(RADV) and can have a retrospective review of records. Regulations which are implemented by ACA can change anytime and that too abruptly. For staying up-to-date, many vendors have established a body of governance, guidance and memoranda. As soon as the changes are announced, this body of governance informs and updates the affected department.

This governance body is liable for evaluating new requirements. Any single department or an individual can’t anticipate the impacts of modified conditions. Expert of each department collectively takes the decision of selecting the best way for responding the new guidelines.

A professional support have its own body of governance for dealing with new guidelines in a better way.

2. Implementing Audit and Quality Assurance Program

A quality assurance program will lead you to meet RADV audits and improve the accuracy of your data. For reaping the benefits of this you need to hire a third party. Your third party will substantiate the HCCs which are documented and are based on medical records.

The IVA (initial validation audit) has to verify the enrollment which is included in the sample of the member. After this whole process gets completed, a second validation of audit (SVA) is conducted by HCC. This focuses on the sub sample of the member whose evaluation of record is done in the IVA.

In case SVA finds huge amount of errors, HHS will confirm that whether payer is having an effective program for quality assurance. This program focuses to ensure that the data is complete, accurate and formatted properly. A solid assurance quality program is an important defense in the cases of False Claim Act.

For enhancing audit program and to get a quality assurance you need to contract with an experienced company that will offer you certified coders and advanced analytics. It will help you to ensure compliance through evaluating under and over coding.

3. Mapping and Improving Data Quality

With the transition of payer organization to risk adjusted payment, data mapping is one process that is scrutinized. Every time data is transferred automatically or manually to other system, there are chances of errors. This frequency of errors increases when standard format of payer is moved to risk scores.

Retrospective review is another process on which payer are focusing. You can submit the corrected ICD codes with retrospective review process. This will help in ensuring that the risk scores are calculated correctly. The players who can conduct retrospective review of all the medical records can achieve 100 percent accuracy in the risk scores.

Make sure to use analytics or enter into a partnership with the one who uses analytics for reviewing drug data and information in order to identify high-risk members and high cost. This result of reviews will improve your accuracy of data and will support programs like educating providers.

HCC risk adjustment is becoming critical for all commercial payers. A comprehensive strategy for risk adjustment is very critical. Keep some of the discussed point in your mind will deliver you an effective and accurate risk scores. You can get the highest quality of retrospective reviews by professional support. This will not only enhance your revenue flow but also will reduce your potential for legal actions which are applicable under the act of False Claims. Try to find a partner who can deliver you the best services like chart retrieval with updated coding technology and even better reporting capabilities.