Take the Risk Out of Risk Adjustment

Updated: Apr 26, 2019

With over 15 years of auditing experience, I have seen many changes in the world of healthcare reimbursement with focus shifting from volume to value. For years, I have been stressing the importance of ICD-10 specificity with supporting documentation. Where Medicare Advantage Plan beneficiaries are concerned, certain diagnosis codes fall into Hierarchical Condition Categories (HCC) and affect the patient’s Risk Adjustment Factor (RAF) score. CMS risk-adjusts payments to Medicare Advantage Organizations (MAO) based on the beneficiary’s higher or lower than average risk score.


Needless to say, diagnosis codes need to be supported and selected to the highest level of specificity to accurately reflect a patient’s risk and health status. Accurate codes equal accurate reimbursements and prevent possible allegations against a provider and MAO receiving higher payments due to inflated risk scores.


As providers and MAOs are finding out, accurate diagnosis coding is important for both the quality of care for their patients and the overall health of the practice. The Department of Justice (DOJ) just announced that a health system in California learned the hard way and paid $30 million to settle allegations of submitting unsupported diagnosis codes resulting in overpayments from CMS to the MAO and provider.


Don’t learn the hard way, Contact Us today to find out more about coding and documenting for accurate risk adjustment with the LHA HCC/Risk Adjustment workshops.


Reference

https://www.justice.gov/opa/pr/medicare-advantage-provider-pay-30-million-settle-alleged-overpayment-medicare-advantage

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