Category Archives: Risk Adjustment (MRA)
Pitfalls in Chart Reviews: Specialist Notes
In this four-part series, we’ve explored so far, the use of suspect reports and issues related to prior medical records. In this installment, we’ll look at what can make specialist notes a little challenging to the chart reviewer. Although the … Read Full Post
Pitfalls in Chart Reviews: Prior PCP Records
In Part 2 of this series on the challenges encountered in chart reviewing for risk adjusted conditions, we’ll discuss the prior PCP. Every single primary care practice has a mechanism for requesting and obtaining records from the patient’s prior primary … Read Full Post
Pitfalls in Chart Reviews: Suspect Reports
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 … Read Full Post
The Balanced MRA Approach
Like grandparents who pepper conversations with comments like, “Back in the day…” we’ve been around the risk adjusted payment methodology since its birth in 2003. Back in the day LOL the provider community was largely in the dark about many … Read Full Post
Substance-induced Disorders may be Incorrectly Supported
From time to time, we run into risk adjusted conditions that are “newly discovered” by coders without fully applying the diagnostic criteria. Those conditions are then suggested to providers, who may not be up on the requirements for the condition … Read Full Post
Some MA Companies Used Questionable Means to Drive MRA Payments
The Office of Inspector General (OIG) audits Medicare Advantage plans for, among other reasons, to assure they submit accurate and true information to the Centers for Medicare and Medicaid Services (CMS) and thereby, receive proper risk adjusted payments. The OIG’s … Read Full Post
Risk Adjustment & the Specialty Provider – Part 3
Welcome back to our last installment of this three-part series on specialty providers and risk adjusted payments. Part 2 of this blog series focused on the substance of consultation notes, while today, we evaluate our topic from the perspective of staff … Read Full Post
Risk Adjustment & the Specialty Provider – Part 2
In Part 1 of this blog, we reviewed the role of specialty providers in risk adjusted payments and their diagnoses of conditions that may fall under the CMS-HCC model. In this installment, we’ll evaluate the substance of those consultation notes. … Read Full Post
Risk Adjustment & the Specialty Provider – Part 1
Without a doubt, risk adjusted payments are geared to primary care providers (PCPs) and form the basis of Medicare Advantage plan payments and usually those of PCPs, whether directly (as in funding) or via surpluses or bonus payments. The same … Read Full Post
Hidden MRA Treasure – Part 4
In this blog series, we’ve been highlighting relatively unknown risk adjusted conditions or ones that bring some confusion; so far, we’ve looked at a few pulmonary disorders, most recently, bronchiectasis. Today, we’ll consider the adrenal nodule, coded E27.9. Found above … Read Full Post