Category Archives: Risk Adjustment (MRA)
ESRD Patients Can Join Medicare Advantage Plans in 2021
As we may know, patients with end stage renal disease (ESRD) have, historically, not been allowed to enroll in Medicare Advantage plans. About 130,000 were grandfathered in through employer-sponsored coverage or developed it after enrolling in MA plans. That will … Read Full Post
CMS Issues Recommendations to Re-Open Health Care Systems in Areas with Low Incidence of COVID-19
On April 19, the Centers for Medicare & Medicaid Services issued new recommendations specifically targeted to communities that are in Phase 1 of the Guidelines for President Trump’s Opening Up America Again with low incidence or relatively low and stable … Read Full Post
Coding Cancers: A Common Charting Error
One of the most common provider charting errors occurs in the area of cancer diagnoses. Practitioners routinely document and code cancers when the patient’s disease has been treated and is no longer evident. For risk adjusted practices, this means the … Read Full Post
Combination Codes
One interesting and time-saving feature of ICD-10-CM codes is the combination code. Just like Burger King, McDonald’s and other fast food eateries, the world of coding has combos; the food-oriented ones save us money and the coding combos save us … Read Full Post
2014 Holds Big Changes for the CMS-HCC Model
The purpose of the CMS-HCC model is to improve the accuracy in predicting the costliness of Medicare Advantage (MA) enrollees’ healthcare costs and to properly fund MA plans for those expenses. It isn’t a perfect model but it surpasses the … Read Full Post
Maximizing the first patient visit of a period
Risk adjusted reimbursement hinges on proper management and reporting of a patient’s chronic conditions. We always advise clients to assess all chronic conditions at least twice per year: once in the period between January 1st and June 30th and again … Read Full Post
What’s the difference between Type 1 and Type 2 Diabetes Mellitus?
According to the American Diabetes Association, diabetes mellitus (DM) is a “group of diseases characterized by high blood glucose levels that result from defects in the body’s ability to produce and/or use insulin.” Insulin is a hormone that helps the … Read Full Post
What We’re Reading – GAO recommends ending CMS bonus payment demonstration
From the GAO.gov website and different healthcare news websites. The Government Accountability Office (GAO), a nonpartisan investigative arm of Congress, recommends that CMS should discontinue its quality bonus program demonstration. The reasons are the budgetary impact, lack of data to … Read Full Post
What We’re Reading – CMS overpaid Medicare Advantage (MA) by as much as $5.1 billion, according to the Government Accountability Office (GAO)
A report issued by GAO the week of March 7, indicates that CMS overpaid the MA program run by private companies by between $3.2 and $5.1 billion for the years 2010-2012. The overpayments were the results of CMS inadequately adjusting … Read Full Post
HEDIS: Is Yours a Five-Star Health Plan?
To most patients, quality is amorphous; we know it when we see it. To a healthcare administrator, however, quality has a whole other meaning. It’s measurable, measured and a measure of the congruence of several factors. In managed care, quality … Read Full Post