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MiraMed - Risk Adjustment HCC Coding Primer 2016


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This presentation outlines the key attributes of risk-adjusted HCC coding

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MiraMed - Risk Adjustment HCC Coding Primer 2016

  1. 1. Coding Service MiraMed Risk Adjustment HCC Coding Primer 2016 HCC Auditing Clinical Documentation Improvement
  2. 2. Risk Adjusted HCC Coding
  3. 3. Healthcare Trends 2016 ICD-10 AccountableCareAct readmission penalty 3
  4. 4. Healthcare Trends 2016 ACO value-based payment 4
  5. 5. About Medicare 5 In-patient SNF Home health Hospice Provider services - office visits Out patient screenings - preventive Hospital emergency - ambulance Supplies - durable med-equipment Medicare Advantage Plans Includes Part A & B Pharmacy benefits Additional services Other
  6. 6. What is Risk Adjustment? A method used to predict costs and adjust payment based on member’s health status and based on the relative risk of the patient’s health status Hierarchical Condition Category (HCC)
  7. 7. It is used to prospectively adjust payment based on health status and characteristics of a enrollee Compares beneficiary to average Medicare beneficiary What is Risk Adjustment?
  8. 8. What is RAF? 8 Risk Adjustment Factor (RAF)  RAF is a calculation to predict the cost of care for beneficiaries  RA score is determined by using all relative factors of one patient for a total year  Demographic and disease information to predict future healthcare costs  A higher score represents the sickest patients
  9. 9. Risk Adjusted Model  Implemented by CMS by the Balanced Budget Act of 1997  Model collects information to establish cost of future patient care  CMS “risk model” is based on measuring chronic conditions
  10. 10. Risk Adjustment Types Medicare Advantage Commercial plans
  11. 11.  Developed by CMS for risk adjustment of the Medicare Advantage Program (Part C)  CMS has an RX HCC model for risk adjustment of Medicare Part D  Medicare - based on age 65 or older  Current year data predictive of future year risk CMS - HCC
  12. 12.  Developed by the Department of Health and Human Services (HHS)  Designed for the commercial payer population  HHS-HCCs predict the sum of medical and drug spending  Includes all ages HHS - HCC
  13. 13. CMS & HHS HCC Programs
  14. 14. HCC Program Summary 14  Medicare Advantage Plans – Part C  Medicare Shared Savings ACO (expected cost)  Value-Based Purchasing (expected cost/efficiency)  Medicaid  Health Insurance Exchange Plans  Commercial carriers  Offers total score for Value Based Purchasing, population health, risk and cost prediction
  15. 15. Why Do Providers Care? 15 STEP 1 - Physician/hospital must document clinical information based on HCC code set Step 1
  16. 16. Why Do Providers Care? 16 STEP 2 - HHS and CMS uses claims data to calculate a patient’s risk score for documentation, coding and billing Step 2Step 1
  17. 17. Why Do Providers Care? 17 STEP 3 - CMS pays insurance payer for HCC accuracy based on providers documentation and coding Step 3Step 2Step 1
  18. 18. Why Do Providers Care? 18 Step 4 Step 3Step 2Step 1 STEP 4 - Payer pays provider based on correct HCC codes - accuracy means more revenue for provider
  19. 19. Why Do Providers Care? 19  CMS audits to ensure integrity and accuracy of risk-adjusted payment – compliance risk  Medicare Advantage plans can be selected for RADV Audits annually to validate diagnosis  Providers are required to assist in RADV Audits RISK ADJUSTMENT DATA VALIDATION AUDITS (RADV)
  20. 20. Why Do Providers Care? 20 HCC reimbursement rates are increasing over the next three years There is a financial benefit to the provider and payer for correctly capturing all HCC codes There are approximately 10,000 codes that map to HCCs that need to be understood and captured
  21. 21. Why Do We Care? 21  HCC is now on the provider’s radar  We can audit medical records to find gaps in HCC coding  Reduce provider risk due to a lack of compliance  We can assist providers with clinical documentation and education
  22. 22. MiraMed HCC Services 22  Provide retrospective audits current timeframe or lookback 12 months  Identify and document missed HCC codes to increase provider revenue  Offer year-end, quarterly or ad- hoc auditing  Provide on-site CDI education and training services
  23. 23. Delivering HCC Services 23  Use all offshore auditors with a ramp up timeframe of 60 to 90 days  Use all onshore auditors supplied by MMOC  Use MMOC auditors for quick ramp up and supplant US coders with our offshore team
  24. 24. Prospect Contacts 24 Hospital  CFO  VP Revenue Cycle  VP of Managed Care  Manage Care Executive  VP of Coding Physician Group  Manage Care Executive  Group Administrator  ACO Executive Director
  25. 25. Value Proposition 25  36 year successful revenue cycle track record  15 years of coding experience  Code over 30 million charts annually – all specialties  Deliver consistent 95 % accuracy  Team’s experience: MD, RN, AHIMA/AAPC Certified - CPC, CPMA, CPCO, CEDC, CCS, CCS-P, CIC, CPMA, AHIMA ICD-10- CM/PCS Trainers
  26. 26. Q&A 26
  27. 27. Coding Service MiraMed Risk Adjustment HCC Coding Primer 2016 HCC Auditing Clinical Documentation Improvement