Our company began working with risk adjusted payments in 2004, shortly after the CMS-HCC model was implemented, and as you can imagine, we’ve reviewed thousands of medical charts. Over the years, as providers from all specialties have become more versed in medical coding and MRA, we’ve seen an evolution in the pitfalls that reviewers can encounter when auditing charts. This series will explore four common issues and our suggestions for avoiding mistakes. In Part 1, we’ll discuss suspect reports.
Suspect reports are lists of risk adjusted medical conditions that health plans believe may apply to specific patients. The plans provide these lists to provider offices and request the staff “work” the lists. This means chart reviewers should determine whether the suspected conditions are valid (e.g., there is evidence to support them) and then suggest that providers assess and report them at the next visit. At first blush, this sounds like a great help to provider offices in making sure no valid conditions are being overlooked. Reality, however, doesn’t bear this out. (Our health plan colleagues will probably cringe, but we’ve got to share our honest perspective with you.)
Suspected conditions are pulled from many sources: hospitalizations, lab and other provider data, medication use and even plan algorithms that supposedly can pinpoint possible medical conditions. What results is, essentially, a wild goose chase, assuming the practice has a process for reviewing documents from any provider who sees the member and determining whether there are new conditions to assess. Suspect reports rarely contain the name of the provider source or date of service, which makes this an even more frustrating and time-consuming exercise with little return on investment.
In addition, let’s not forget that hospitals, for example, are subject to different coding rules than medical professionals in outpatient settings. Inpatient claims may contain codes for differential diagnoses or rule-out conditions that can ultimately find their way into suspect reports. Consequently, taking them at face value can result in errors for the practice.
A better source of potential conditions is a report of claims paid on behalf of your patients, if it’s possible to obtain that from your plan. A claims report will provide a date of service and ICD-10-CM codes reported for your patient. The practice can then request specific records from the provider source and determine whether the conditions are valid for the patient. It may be valuable to work both types of reports and track success rates in validating new conditions. This will give you data with which to reassure your MA plan rep that you’re doing the work, just a little differently.
In the next installment of this blog series, we’ll discuss the value and hazard of prior PCP records.