Category Archives: Risk Adjustment (MRA)

2014 Holds Big Changes for the CMS-HCC Model

The purpose of the CMS-HCC model is to improve the accuracy in predicting the costliness of Medicare Advantage (MA) enrollees’ healthcare costs and to properly fund MA plans for those expenses. It isn’t a perfect model but it surpasses the … Read Full Post

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Maximizing the first patient visit of a period

Risk adjusted reimbursement hinges on proper management and reporting of a patient’s chronic conditions.  We always advise clients to assess all chronic conditions at least twice per year: once in the period between January 1st and June 30th and again … Read Full Post

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What’s the difference between Type 1 and Type 2 Diabetes Mellitus?

According to the American Diabetes Association, diabetes mellitus (DM) is a “group of diseases characterized by high blood glucose levels that result from defects in the body’s ability to produce and/or use insulin.”  Insulin is a hormone that helps the … Read Full Post

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What We’re Reading – GAO recommends ending CMS bonus payment demonstration

From the website and different healthcare news websites. The Government Accountability Office (GAO), a nonpartisan investigative arm of Congress, recommends that CMS should discontinue its quality bonus program demonstration. The reasons are the budgetary impact, lack of data to … Read Full Post

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What We’re Reading – CMS overpaid Medicare Advantage (MA) by as much as $5.1 billion, according to the Government Accountability Office (GAO)

A report issued by GAO the week of March 7, indicates that CMS overpaid the MA program run by private companies by between $3.2 and $5.1 billion for the years 2010-2012. The overpayments were the results of CMS inadequately adjusting … Read Full Post

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HEDIS: Is Yours a Five-Star Health Plan?

To most patients, quality is amorphous; we know it when we see it. To a healthcare administrator, however, quality has a whole other meaning. It’s measurable, measured and a measure of the congruence of several factors.  In managed care, quality … Read Full Post

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What does it mean to be “at risk?”

The concept of being “at risk” has to do with the level of financial risk the entity has in funding the care its patients receive.   As profit-oriented enterprises, insurance companies generally assess the insured’s risk and base the premium on … Read Full Post

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CMS Risk Adjustment Data Submission Deadlines and Payment Schedule

The nature of capitation and the risk adjustment payment method requires specific deadlines for data submission that correlate to dates of service and affect capitation payments.  The Centers for Medicare and Medicaid Services (CMS) observes the following three deadlines each … Read Full Post

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How are Depression and Major Depression Different?

According to Barron’s Medical guide Dictionary of Medical Terms, Fifth Edition by Mike A. Rothenberg, M.D., and Charles F. Chapman, depression (ICD-9-CM code 311) is a dejected state of mind with feelings of sadness, discouragement, and hopelessness, often accompanied by … Read Full Post

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Coding Cancers: A Common Charting Error

One of the most common provider charting errors occurs in the area of cancer diagnoses.  Practitioners routinely document and code cancers when the patient’s disease has been treated and is no longer evident.  For risk adjusted practices, this means the … Read Full Post

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