Are you:
Keeping up to date with your risk scoring?
Missing out on reimbursement premiums?
Ensuring accurate health profiles for your patients?
Proper risk adjustment is important, not only to ensure your patients' quality of care, but also to improve your bottom line. This CareOptimize presentation will take you from the basic tenets of risk adjustment to specific ways you can increase your risk scores and get the highest premium payments.
2. Risk Adjustment
What is it?
Methodology accounting for known and/or discovered health data elements
and levels comparisons of wellness among patients.
Used as a method to evaluate all patients on an equal scale.
3. Determining Factors
Risk adjustment modules utilize diagnosis codes
to determine potential patient level risks.
• Age
• Gender
• Socioeconomic Status
• Disability Status
• Insurance status
- Medicare
- Medicaid,
- Dual-eligible, etc.
• Claims data elements such
as procedure codes, place of
service codes, etc.
• Special patient-specific
conditions (enrolled in hospice or
being an ESRD patient)
ADDITIONAL ELEMENTS
4. Risk Adjustment Modules
Diagnosis based programs
HHS
Health and Human Services
Hierarchical Condition Category
CDPS
Chronic Illness and Disability
Payment Systems
HCC-C
Hierarchical Condition
Category, Part C
DRG
Diagnosis Related Groups
ACG
Adjusted Clinical Groups
5. Medicare
Hierarchal Condition Categories
• Model used by MA plans
• Takes ICD codes and filters them into Diagnosis
Groups, then into Condition Categories
• Assigns a value to each diagnosis code in the model
• Each diagnosis code carries a Risk Adjustment Factor
6. How does Risk Adjustment
Affect You?
• Physicians will treat patients on plans
funded through RA models
• Plans expect providers to document and
code diagnoses correctly
• Physician documentation and coding
establishes the complexity and
workload of patient panels
• Documentation and diagnoses become
the basis for funding and
reimbursement
?
7. How is the risk (RAF)
score developed?
Each patient has a RAF score made of:
Baseline demographic elements (age/sex and dual eligibility status)
Incremental increases based on HCC diagnoses submitted on claims from
face-to-face encounters with qualified practitioners during the calendar year
HCC coding is prospective in nature:
The work you do in this year sets the RAF and subsequent funding for next
year
All models include chronic conditions that do not change from year to year:
Diabetes, COPD, CHF, Atrial-Fib, MS, Parkinson’s, Chronic Hepatitis
8. Correct Coding
• Adherence to ICD-10 guidelines is required
under HIPAA
• Documentation must show condition was
monitored, evaluated, assessed, or treated
(MEAT)
• A diagnosis code may only be reported if it
is explicitly spelled out in the medical
record
• No coding from problem lists, super bills,
or medical history
Treatment is prima facia evidence of a diagnosis—
if you are treating, it exists
9. MEAT the Chronic Condition
Monitor
Signs
Symptoms
Disease progression
Disease regression
Evaluate
Test results
Medication effectiveness
Response to treatment
Assess
Ordering tests
Discussion
Review records
Counseling
Treat
Medications
Therapies
Other modalities
M E A T
11. Risk Adjustment Data Validation
• CMS identifies a random stratified sample of patients to audit.
• Only Part C HCCs are audited in a RADV.
• Health plans must submit up to five best records demonstrating
diagnoses that support the HCC values paid as current in the year being
audited.
• Supplemental diagnoses (those not originally submitted via claims) may
be approved if they are documented as current diagnoses in the record.
• E submission of all diagnoses (with HCCs) are cumulative, so there may
be a negative or positive financial outcome overall in such an audit.
12. Health and Human Services
HCC Model
• Section 1343 of the Affordable Care Act (ACA) calls for a risk adjustment model.
Health and Human Services (HHS) created a risk adjustment model based on the
HCC classification system; however this model was developed using commercial
claims.
• The hierarchical grouping logic is similar to the Medicare methodology, but HHS
selected a different set of HCCs for the federal risk adjustment methodology to
reflect the population differences.
• Patients are grouped in this model by age (adult,child,infant) and by metal
(platinum, gold, silver, and bronze).
• This plan does not currently review prescription-based diagnoses such as those
found in the HCC-D used by Medicare.
13. ACA Plan
ACA Plan Category The insurance
company pays
The patient pays
Platinum 90% 10%
Gold 80% 20%
Silver 70% 30%
Bronze 60% 40%
Catastrophic Less than 60% More than 40%
14. Medicaid Chronic Illness and Disability
Payment System (CDPS)
• In the Medicaid Chronic Illness and Disability Payment System (CDPS)
risk adjustment model, there are far more diagnosis codes identified
than are included in the Medicare HCC model
• While these CDPS diagnoses also carry a numeric value for risk, they are
also rated as “high,” “medium,” and “low” risk overall.
• This rating is used in hierarchal value setting. Where low is trumped by
medium and medium is trumped by high.
• Uses data from both claims and Medicaid prescriptions (MRx)
15. Cardiovascular Category
CARVH
3 Stage 1
groups
7 diagnoses
CARM
13 Stage 1
groups
53 diagnoses
CARL
26 Stage 1
groups
314 diagnoses
CAREL
2 Stage 1
groups
35 diagnoses
Four Levels
The suffix of the Cardiovascular Category (CAR)
establishes its place in the hierarchy:
• VH (Very High) (weight 2.037): heart transplants, valves, etc.
• M (Medium) (weight 0.805): heart attacks, etc.
• L (Low) (weight 0.368): heart disease, etc.
• EL (Extra Low): hypertension, etc.
18. MIPS and Risk Adjustment
HCC coding is the system that will be used for Risk Adjustment under
MIPS.
At its core, diagnosis codes (ICD-10) are assigned a weight that measures patient
acuity. Medicare expects that patients with higher HCC scores will consume more
healthcare dollars and have worse outcomes.
If 60% of the MIPS score for providers is going to come from risk adjusted quality and
resource use scores, it is critically important to accurately reflect the acuity of their
patient population. Doing so will allow their quality and cost scores to accurately
reflect the excellent care provided by physicians.
Your diagnosis coding is about to become much more important, both for
immediate fee-for-service reimbursement and over the following two years
as Medicare uses that diagnosis data for Risk Adjustment under MIPS.
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We know the benefits of this model because we use it every day in our five
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Healthcare Experts
Our consultants keep up to date with the latest in healthcare technology and
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All-Inclusive Healthcare Services
From basic needs to specialized care, we are able to provide the very best in
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Our experience and capabilities result in increasing value while reducing costs
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21. Baseline Premium $710.00
PREMIUM $710.00
Baseline Premium $710.00
PRIMARY PULMONARY
HYPERTENSION * .398
CHRONIC KIDNEY
DISEASE STAGE II MILD
*.357
DIABETES WITH RENAL
MANIFESTATIONS
*.585
PREMIUM $1661.40
*examples based on 79 year old male
Accurate HHC Coding:
Proven Revenue Producer
22. CareOptimize Coding Module
• Integrates into the physician workflow at
the point of care (Inside EHR)
• Automates coding gaps detection for more
accurate coding and risk scoring
(Identify missed HCC codes)
• Conducts prospective and retrospective
coding (Improve RAF scores)
• Analyzes projected coding patterns and
provider documentation gaps
• Improves care planning and patient
outcomes