Category Archives: Risk Adjustment (MRA)
Substance Dependence: Do Your Charts Support it?
Drug and alcohol addiction are under the umbrella term of substance dependence in the DSM-V. ICD-10 includes them all under the heading Mental and behavioral disorders due to psychoactive substance use, which is coded from F10 to F19. In the … 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
“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
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
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
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
Wanna Bet Not All Your MDDs Are Valid?
Major Depressive Disorder (MDD) is fast becoming one of the most poorly supported conditions we find during audits, and it may stem from the fuzzily documented distinction between depression and major depression. After all, not all depression fits in the … Read Full Post
Reminders for Proper Documentation
We all know providers are stressed for time and want to provide the best medical care to each and every one of their patients even in a short window of time. Unfortunately, the first thing to suffer is the documentation … Read Full Post
F2F or Virtual Education – Which is Right for You?
Organizations and venues that rely on conventions, conferences and sizable meetings are hard-hit because of the COVID-19 crisis and the jury is out on how well these activities will bounce back from the shut-downs. Zoom meetings seem to have become … Read Full Post
Telehealth & MRA
There is much miscommunication regarding the use of telehealth services to report risk adjusted diagnoses. In the early days of COVID-19, CMS stated that it would pay for telehealth services that were conducted in an interactive format using both audio … Read Full Post