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 aspects of this huge payment shift. Remember that in the early aughts, MA payments were based on factors beyond the provider’s control, namely demographics, and documentation was deliberately sparse in prepaid circles because it wasn’t believed to matter to the payment. (That’s the subject of another discussion.) Additionally, the majority of providers were documenting visits on paper. Raise your hand if you remember the blue paper problem list filed on the left side of the chart!
So much of our work in early MRA was educating providers and identifying risk adjusted conditions buried in the chart – conditions which had not been previously coded or reported. That’s perhaps the “fun” part of MRA work: unearthing conditions that may add to the provider’s (or Plan’s) funding. With time, things shifted and providers were more informed on the conditions under the CMS-HCC model and better at coding them. In time, regulators stepped up their scrutiny of reported conditions and documentation to assure proper compliance with all guidelines, coding and medical. Cue the OIG. As we’ve reported many times over the years, the Office of the Inspector General (OIG) has commissioned numerous audits of MA plans, questioning the validity of submitted conditions and even making serious accusations of fraudulent activities and “upcoding.” That’s the non-fun part.
The balanced MRA approach, therefore, has to embrace the two: identifying new conditions that fall in the CMS-HCC model which have not been reported and assuring that the submitted codes are valid. Valid encompasses: using the most specific ICD-10-CM code possible; making sure the evidence supporting the condition is clear, documented and accurate; and requiring comprehensive documentation of a proper assessment of the condition on the date of service for which it is reported.
In our work, we get to see the MRA activities of many practices, large and small. Some are heavily slanted toward identifying new conditions – however creatively – but they disregard the validation aspect at their own peril. A few are exclusively archaeologically inclined! We urge every single provider operating under this payment method to assure your MRA department’s activities are equally split between identifying unreported conditions and making sure what has been submitted will pass muster.