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 conditions that support higher payments. It is alleged that Cigna focused its HRA efforts on “targeted” members expected to yield the highest return on investment, incentivized PCPs to attend educational programs aimed at identifying MRA conditions, and expected the vendor’s staff to record 20 or more diagnoses on each in-home HRA. Let’s look at each of these issues separately.
Beginning with the understanding that the progress note is a legal document that conveys a clinician’s diagnosis, assessment and management of medical conditions, it stands to reason that all the diagnoses that affect the patient’s health status will be assessed – all, as in regardless of their weighted payment. It’s certainly suspicious to us when a progress note contains only MRA codes despite a plethora of other conditions on the active problem list. Reporting only weighted codes when other conditions are relevant to the encounter raises a flag that the purpose of the encounter might be financial and not health-related. As always, the clinician’s documentation, which would convey the need to assess these conditions, will seal the deal. If only vague, copy/paste statements are included, financial-only motives may loom large. We strongly suggest all providers consider the patient’s chief complaint (reason for the visit), document a solid case for all the diagnoses assessed at the visit and remember to include a review of non-risk adjusted conditions that are relevant to the encounter.
Next is the idea of segmenting the patient population to focus on those patients who are more likely to have MRA diagnoses. Time and personnel are not infinite and there will always need to be a system of assessing risk adjusted payment efforts. However, we believe the intention to code all conditions correctly is important. Administrators consider high claims expense for patients with low risk scores, for example, to be one indicator of possible improper coding. A case-by-case review is needed – from multiple managed care angles – to assure care is appropriate and for conditions that are properly coded. Segmentation works both ways, and equal consideration should be given to identifying conditions that are generally improperly coded, such as cancers, heart failure and major depression. A balanced review of the patient population and its risk adjusted conditions can support the intention to code correctly and not just to focus on increasing revenue.
Incentives tied to increasing revenue are obviously problematic, and can be illegal, and we strongly suggest you ask a healthcare attorney to review your clinician incentive programs. That said, measurable activities, such as proper coding, may form part of an incentive program. Again, we believe intention is the key. Provider groups assess many aspects of clinician activity, including utilization. Assessing diagnosis coding specificity and correctness, as well as thoroughness of documentation (e.g., all SOAP elements, charted evidence, E/M coding), should be part of your practice compliance program. Your practice also needs a mechanism for handling and remediating coding errors.
Clinician and coder education are necessary and should be ongoing. As codes change, guidelines are revised, and documentation review programs require, all constituents should be re-educated periodically with targeted re-training as appropriate. This brings us to coding and MRA staff. It’s not enough to expect coders to take continuing education; after all, CEUs are required to maintain their credentials. However, there is no requirement for the type of educational programs your coders attend. They can learn about anesthesia, bariatric surgery and setting bone fractures, and receive credit, none of which remediate faulty MRA coding. Your compliance plan should include a mechanism for regularly assessing the accuracy of your coding staff and for maintaining their knowledge of medical and coding guidelines. Here is a blog that provides more detail.
Lastly, an expectation of the number of reported codes is obviously fraught with peril for any payment paradigm. Codes for diagnoses and procedures are determined by the clinician based on the parameters of each visit. The borders of the visit, for lack of a better word, are the SOAP elements, which convey the focus. To expect a number of diagnoses from an encounter is – on its face – an invitation to over-report. The better approach arises from the intention to code correctly, which means that the conditions reported on a visit should naturally stem from the charted SOAP elements. They should make sense based on the chief complaint, history of present illness, and other parameters of the E/M visit.
Another issue to consider is the number of conditions reported. In today’s EMR environment, it’s not difficult for an auditor to determine how long the clinician visit took to complete; the reporting of an unusually long list of conditions (the highest we’ve seen is 60+!!) raises the suspicion that the conditions were not really assessed. After all, even the best clinician with lightning-speed typing or a scribe cannot properly assess 20+ medical conditions in a 15-minute visit! The flip side is just as problematic: limiting the number of risk adjusted conditions that can be reported in a single encounter. Remember that what is reported comes from all the elements of the visit, and there is no way to predict or mandate what that will be ahead of time.
In short, tools such as the HRA, member segmentation and incentives depend to a large degree on intention and how we use these to improve patient care. If the goal is patently to generate revenue – in FFS or capitated environments – you can expect more scrutiny. It’s always best to get ahead of the regulator magnifying glass by assessing your internal MRA processes as mentioned above and making changes where needed.
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