Downloaded 41 times
Uploaded byBen Quirk
Risk Adjustment: Determining Risk Determines Reward
Risk adjustment is a methodology used to evaluate patient wellness by accounting for various health data elements, ensuring equitable comparisons among patients. It involves determining factors such as age, gender, socioeconomic status, and specific conditions to assess patient-level risks, influencing funding and reimbursement for healthcare providers. Accurate documentation and coding are crucial for reflecting patient acuity, which impacts the financial outcomes under risk adjustment systems, particularly for Medicare and Medicaid plans.
More Related Content
![Presentation on How to Encounter CMS & HHS RADV Audits [CEU]](https://cdn.slidesharecdn.com/ss_thumbnails/risk-adjustment-webinar-170810065012-thumbnail.jpg?width=640&height=640&fit=bounds)
Similar to Risk Adjustment: Determining Risk Determines Reward
Risk Adjustment: Determining Risk Determines Reward
- 2. Risk Adjustment What isit? 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 adjustmentmodules 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 Diagnosisbased 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 RiskAdjustment 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 therisk (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 • Adherenceto 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 ChronicCondition 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
- 10. HCC Financial Differences inCoding Specificity
- 11. Risk Adjustment DataValidation • 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 HumanServices 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 PlanCategory 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 Illnessand 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 Stage1 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.
- 16. Why is HCCRisk Adjustment Important ?
- 17. CMS RA PaymentSchedule
- 18. MIPS and RiskAdjustment 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.
- 19. Care Holdings Group ComprehensiveValue Based Healthcare Services Full risk Independent Physician Association -- More than 100 providers to date Network of five full risk, fully owned Medicare Advantage centers -- Focused on care coordination & preventative medicine Shared Risk, Commercial ACOs -- Shared Risk Medicare ACOs -- Full spectrum healthcare ecosystem Consulting professionals expert in healthcare regulatory and technology strategies -- Shared Upside partnerships All-inclusive optical services ALSO AVAILABLE Dental Services -- Pharmacy Services
- 20. Benefits of The CareHoldingsGroup Network Full-Risk, Proven Model We know the benefits of this model because we use it every day in our five Medicare Advantage centers and with our providers in our MSO. Healthcare Experts Our consultants keep up to date with the latest in healthcare technology and regulatory issues, maximizing revenue and optimizing services for every practice. All-Inclusive Healthcare Services From basic needs to specialized care, we are able to provide the very best in healthcare services. Value Based Focus Our experience and capabilities result in increasing value while reducing costs and raising quality scores.
- 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
- 23. CareOptimize Coding Module StratifyPatients by RAF Score Potential Patient Specific RAF Scores and Opportunity Count
- 24. CareOptimize Coding Module PatientSpecific HCC Code History and RAF Score
- 25.