Tag Archives: medicare risk adjustment

MRA & The New Patient Visit

In our years of reviewing charts, we’ve observed new PCP visits where the clinician assigns diagnoses based on the medications the patient is taking, adds them to the problem list and includes them in the assessment of the visit. Let’s … Read Full Post

Tagged diabetes, medicare risk adjustment, mra, pre-diabetes, risk adjusted reimbursement |

WWR – Kaiser agrees to pay $6.4 million to settle claims it received inflated Medicare Advantage payments

Kaiser joins the undignified ranks of the companies investigated for committing fraud. This timely article from Healthcare Finance News doesn’t use that word, but it describes the finding that Kaiser “knowingly submitted” false diagnoses to inflate its payments, which is … Read Full Post

Tagged coding compliance, medicare advantage, medicare risk adjustment, mra, risk adjusted reimbursement |

Lessons from the Cigna/DOJ Lawsuit: Health Risk Appraisals (Part 2)

Last week’s first installment of this blog started our review of HRAs in the MRA environment. Let’s continue searching for lessons to apply in your practice. A third issue with Cigna’s HRAs was the supposed expectation to capture all the … Read Full Post

Tagged Cigna, cms, coding compliance, DOJ, HCC, health risk appraisal, HRA, medical coding, medical documentation, medicare advantage plans, medicare risk adjustment, mra, risk adjusted reimbursement |

Compliance Tool-kit Should Include External Validation

Although all providers should have a Compliance Program, it seems that mostly larger groups have them in place and even then, to varying degrees. Many practices have some form of internal validation of a coder’s work; most of the time, … Read Full Post

Tagged auditing, coding compliance, compliance, HCC, medicare risk adjustment, mra, validation |

Documentation for Risk Adjusted Payment

The concept of medical documentation has usually focused on those elements supporting the evaluation and management (E/M) code selection in fee-for-service payment environments; electronic medical records (EMRs) have done a great deal to alleviate the charting burden for these clinicians. … Read Full Post

Tagged charting, M-E-A-T, medical documentation, medicare risk adjustment, mra, T-E-A-M |

Lessons from the Cigna/DOJ Lawsuit: Health Risk Appraisals (Part 1)

This blog is the first in a series of lessons, or reminders, gleaned from the Department of Justice’s (DOJ) lawsuit against health insurer Cigna. The suit alleges that Cigna essentially committed fraud by reporting false information to CMS in a … Read Full Post

ADA Changed Diagnostic Guidelines

From time to time, it’s important to revisit established diagnostic criteria for frequently encountered conditions because medicine evolves. One such change occurred in the diagnostic guidelines for diabetes. The standard was primarily one A1c of 6.5% or two fasting blood … Read Full Post

Tagged diabetes, diagnosing diabetes, DM, medicare risk adjustment, mra, risk adjusted reimbursement |

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

Tagged cancer diagnoses, capitation, charting errors, coding cancer, documentation, medicare risk adjustment, mra, risk adjusted reimbursement, risk adjustment |

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

Tagged annual wellness visits, center for medicare and medicaid services, chronic kidney disease, cms-hcc model, ffs medicare, government accountability office, health risk appraisals, hierarchical condition categories, medicare advantage enrolles risk scores, medicare advantage plans, medicare payment advisory commission, medicare risk adjustment, mra, national institutes of health, national kidney foundation, risk adjustment in medicare advantage, risk scores, the patient protection and affordable care act |

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

Tagged chronic conditions, cms-hcc model, documentation, health risk assessment, hospital admissions, medicare risk adjustment, mra, patient visit, pcp assessment, reimbursement, risk adjusted reimbursement |