Tag Archives: risk adjusted reimbursement

Supporting a Diagnosis of Angina Pectoris

In a primary care setting, we sometimes encounter patients who have been diagnosed with angina pectoris and are being followed by the primary care practitioner (PCP). In this blog, we will share some of the most common issues regarding this … Read Full Post

Tagged angina, chest pain, medical coding, mra, risk adjusted reimbursement |

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 |

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

The DOJ Targets MA Plans

The Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) reported that a study conducted in 2019 revealed, “Unsupported risk adjusted payments are a major driver of improper payments in the Medicare Advantage (MA) … Read Full Post

Tagged Anthem, Cigna, DOJ, fraud, HCC, medical coding, medicare advantage plans, mra, risk adjusted reimbursement |

“Removals” is not a bad word!

“You are leaving money on the table” is a common phrase Medicare Advantage providers hear from some auditors and even health plans regarding members’ risk scores. And that might be true. Some risk adjusted diagnoses may have fallen through the … Read Full Post

Tagged funding, mra, removals, risk adjusted reimbursement, risk adjustment |

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 |

What We’re Reading – DOJ Launches Lawsuit Against Anthem for Risk Adjustment Fraud

As detailed in this article, Anthem is facing a lawsuit initiated by the Department of Justice (DOJ) for allegedly failing to remove erroneously submitted diagnoses from CMS’s database despite knowing that inconsistencies might be present. The health insurance carrier commissioned … Read Full Post

Tagged coding compliance, DOJ, icd-10, inflated risk score, mra, MRA program, risk adjusted reimbursement, risk adjustment, risk score |

Why Is July Relevant for MRA?

Risk adjusted reimbursement is based on the health status of the patient as summarized by certain ICD-10-CM codes reported by the provider. The reporting timeframe is twice per year in order to maintain stable funding; PCPs should assess, document and … Read Full Post

Tagged funding, mra, risk adjusted reimbursement |