Category Archives: Risk Adjustment (MRA)
Public Health Emergency Extended
The Department of Health & Human Services announced on Friday that it is extending the PHE until January 16, 2022. This means that all of the waivers remain in place. This is good news for providers and patients who have … Read Full Post
Hidden MRA Treasure – Part 3
In Part 2 of this series, we spent a little time considering J84.10 and the specific diagnosis of granuloma of the lung. In this installment, we’ll look at another oft-neglected pulmonary diagnosis of bronchiectasis, coded J47.9. According to the National … Read Full Post
PMH isn’t Code-able – A Cautionary Tale
Before our discussion of the term past medical history (PMH), let’s briefly reflect on the risk adjusted payment paradigm, or MRA as it’s known in Medicare Advantage circles. CMS bases the bulk of the capitation payment made to MA plans … Read Full Post
Hidden MRA Treasure – Part 2
In Part 1 of this series, we reviewed ICD-10-CM code I77.1 and explained that there are some often overlooked conditions that increase your risk adjusted payments. This time, we’ll focus on ICD-10-CM code J84.10, Pulmonary fibrosis, unspecified. This code was … Read Full Post
Hidden MRA Treasure – Part 1
In the early days of the CMS-HCC model, providers were not versed at all on the inner workings of the risk adjusted payment paradigm or the conditions included. And admittedly, much has changed in these 18 years. Most providers know … Read Full Post
Kaiser Permanente: Most Recent to Fall Under DOJ Scrutiny
Kaiser Permanente is the latest Medicare Advantage (MA) plan to be embroiled in allegations of False Claims Act violations for risk adjusted coding activities. As you might recall, Humana was flagged for reporting unsupported risk adjusted diagnoses, Anthem allegedly failed … Read Full Post
MRA Issues from the Trenches
We have blogged quite extensively on all things MRA and especially the need for solid documentation. Historically, a provider’s charting improves when the spotlight is shined on it, but old habits are hard to break; we find that, sadly, documentation … Read Full Post
Anthem OIG Audit Reveals Coding Issues
Last month, the Office of Inspector General published the report of a compliance audit conducted on one of Anthem Community Insurance Company, Inc.’s Medicare Advantage (MA) contracts. The OIG concluded that Anthem was overpaid by $3.4 million. MA plans’ payments … Read Full Post
OIG Finds Errors in Humana Compliance Audit
When the Centers for Medicare and Medicaid Services (CMS) risk adjustment data validation (RADV) audit identified coding errors for one Humana contract representing members in South Florida, the Office of Inspector General (OIG) conducted its own audit. We should recall … Read Full Post
A Fundamental Disconnect of Risk Adjustment Documentation
When CMS launched the risk adjustment model for Medicare Advantage payments beginning in 2003, the reason for the change – in many minds – was shortened to, essentially, being paid more for sicker members. While this is one part of … Read Full Post