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 between July 1st and December 31st. We often review a patient’s chart and see that the first visit of the year was for an urgent condition, which the physician treated; the provider also noted that he or she would complete an exam on the next visit. Too often, patients fail to keep those follow up appointments. In addition, the appointments sometimes occur long after the initial urgent visit.
Why is this an issue? First of all, chronic conditions require regular management to prevent acute events. Acute events are expensive (in terms of medical costs and in their toll on the patient’s health), and a schedule of regular visits will minimize emergency department visits and hospital admissions. In addition, from a risk adjusted reimbursement standpoint, the provider (or the group or plan) incurs expenses in the regular management of chronic conditions. They range from medication expenses to specialty consults. Without a PCP’s assessment, documentation and coding of those conditions – many of which fall under the CMS-HCC model – the funding may be incorrect or inadequate to cover the cost of the care the patient has received. Moreover, if the patient should die prior to that follow-up appointment, the opportunity to report those conditions is permanently lost and the funding for the period will be incorrect.
We urge all clients to develop a campaign to bring all patients in at least twice per year and to make sure patients receive a thorough health risk assessment. Not only is this good for the patient, but it’s vital for the practice. Finally, review the documentation and coding to ensure all the conditions are properly substantiated. This will result in proper payments and minimize the likelihood of retroactive funding adjustments.