As a healthcare provider, it’s essential to understand the importance of accurate HCC (Hierarchical Condition Category) coding. HCC codes are used to classify patient conditions, which determines Medicare Advantage payments. Inaccurate HCC coding can have serious consequences for both your practice and your patients.
Inaccurate HCC Coding Impacts Revenue
One of the most significant risks of inaccurate HCC coding is financial loss. When codes are not reported correctly, the capitated payments for your patient care will be lower than they should be. This can have a significant impact on the bottom line of your practice, and it can be difficult to recover lost revenue. Furthermore, practices may also be subject to audits or investigations if it is found that they have submitted inaccurate codes. These can be costly and time-consuming, and often result in fines and penalties.
Inaccurate HCC Coding Impacts Patient Care
Inaccurate HCC coding can also negatively impact the care that your patients receive. The codes are used to identify patients who have complex health conditions, and when codes are not reported accurately, these patients may not receive the additional resources they need. This can result in poorer health outcomes and increased healthcare costs down the line.
Inaccurate HCC Coding Impacts Compliance
Another major risk of inaccurate HCC coding is compliance. If your healthcare providers are not be aware of the latest coding guidelines and regulations, that can lead to coding errors. Inaccurate coding can result in compliance violations and non-compliance with laws and regulations can result in penalties and legal issues.
Inaccurate HCC Coding Is Not Mandatory
In order to mitigate these risks, it’s essential that healthcare providers are trained and stay up-to-date with HCC coding guidelines and regulations. Your organization already invests in education and training for your staff, and you likely use coders and coding software that can help identify coding errors and ensure compliance. But this is not enough.
Fix Inaccurate HCC Coding With DoctusTech
The DoctusTech HCC coding education app is not only the best way to train clinicians, it is also the only way to measure your clinicians’ HCC coding knowledge while they learn. Training in our app helps providers to ensure that they are accurately diagnosing coding patient conditions and maximizing reimbursement.
Mitigate The Impacts Of Inaccurate HCC Coding
Accurate HCC coding is vital for the financial success of your practice, and for ensuring that your patients receive the care they need. Investing in training that really works and using technology tools to help you stay compliant can help you to mitigate the risks of inaccurate HCC coding.
Learn more about the DoctusTech app trains clinicians on more than which code to pick – it teaches them what to look for, what to test, and how to document for RISK in a Value-Based Care arrangement, to ensure that every HCC category is captured and every patient receives care for every condition. And because it is in an app, clinicians can do their training whenever and wherever, in just five minutes a week. And admins have total visibility into clinician engagement, learning progress, retention and growth, so your team will know which clinicians need a little extra coaching.
Stop Missing Diagnoses and HCC Categories
Do you want to stop missing HCC codes, categories and diagnoses? Schedule a demonstration of the DoctusTech app and start on the path to success in VBC. Schedule your demonstration here.
Values-based healthcare reimbursement has been adopted more quickly in some healthcare sectors than in others.
According to the LAN’s latest APM Measurement report, 40.9% of US healthcare payments—representing over 238 million Americans and more than 80% of the covered population—were generated through value-based reimbursement programs last year. Population-based payments and downside risk agreements were included in these programs, in addition to upside risk agreements.
In addition, almost one fifth (19.8%) of all healthcare payments made last year were in some way tied to value or quality of care while still being based in fee-for-service. The remaining 39.3% of payments were strictly fee-for-service.
Despite the fact that the healthcare industry has adopted value-based reimbursement, adoption is often glacially slow. But values-based reimbursement has been adopted quicker in some segments of the healthcare system.
Where progress is occurring.
According to the APM Measurement report, Medicare and Medicare Advantage are leading the charge in value-based reimbursement – no surprise there.
Just 15.0% of traditional Medicare payments and 38.0% of Medicare Advantage payments were fee-for-service in 2020, down from 2019 data showing 14.1% of traditional Medicare payments and 46.0% of Medicare Advantage payments being fee-for-service.
In both programs, the proportion of value-based reimbursement in two-sided risk alternative payment models continue to increase year over year. In traditional Medicare, 24.2% of payments were part of some two-sided risk model, compared to 20.2% in 2019. In Medicare Advantage, the percentage of payments in two-sided risk models increased from 28.6% in 2019 to 29.3% in 2020.
Insight: Medicare Full Risk grew by 20% between 2019 and 2020.
Medicare Advantage Full Risk grew only 3% in the same period.
Despite fee-for-service payments making up 59.0% of Medicaid payments in 2019, value-based reimbursement adoption increased from 10.6% to 14.5% in 2020.
According to the report, private payers covered 62% of the lives represented in the LAN’s data, but only 10.8% of payments made in 2020 were from two-sided risk models, while over half (51.5%) were from fee-for-service.
In addition, a higher proportion of payments to providers from private payers (11.1%) in 2019 was tied to two-sided risk models. Furthermore, 53.5% of payments were fee-for-service, as shown in the report.
How to accelerate value-based payment and risk
Industry experts at the 2021 LAN Summit concur that a lag in value-based reimbursement adoption is shown by the results of the 2020 APM Measurement report. However, there is speculation that risk-based models will be adopted more rapidly over the next few years.
According to the report, 87% of respondents believe that alternative payment model activity will increase; none of them believe it will decrease. In addition, the majority agreed that adoption would lead to higher quality, more accessible care, as well as improved care coordination.
Despite the payors’ perspectives, provider willingness to take financial liability, their capability to implement models, and their interest and willingness are still the greatest barriers to value-based payment adoption.
An “exponential” increase in the level of cooperation between payers and providers has occurred, and more providers are bringing to us the idea of entering into risk arrangements, Shrank said. Because of the outbreak, he thinks more people will be open to working in risk arrangements.
However, payers still must offer the right incentives to incentivize providers to participate in value-based reimbursement and eventual downside risk.
Fred Schulte, Kaiser Health News and Holly Hacker Republished with permission
Newly released federal audits reveal widespread overcharges and other errors in payments to Medicare Advantage health plans for seniors, with some plans overbilling the government more than $1,000 per patient a year on average.
Audits — Hidden Until Now — Reveal Millions in Medicare Advantage Overcharges
Summaries of the 90 audits, which examined billings from 2011 through 2013 and are the most recent reviews completed, were obtained exclusively by KHN through a three-year Freedom of Information Act lawsuit, which was settled in late September.
The government’s audits uncovered about $12 million in net overpayments for the care of 18,090 patients sampled, though the actual losses to taxpayers are likely much higher. Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by major insurance companies.
Officials at the Centers for Medicare & Medicaid Services have said they intend to extrapolate the payment error rates from those samples across the total membership of each plan — and recoup an estimated $650 million as a result.
But after nearly a decade, that has yet to happen. CMS was set to unveil a final extrapolation rule Nov. 1 but put that decision off until February.
Ted Doolittle, a former deputy director of CMS’ Center for Program Integrity, which oversees Medicare’s efforts to fight fraud and billing abuse, said the agency has failed to hold Medicare Advantage plans accountable. “I think CMS fell down on the job on this,” said Doolittle, now the health care advocate for the state of Connecticut.
Doolittle said CMS appears to be “carrying water” for the insurance industry, which is “making money hand over fist” off Medicare Advantage. “From the outside, it seems pretty smelly,” he said.
In an email response to written questions posed by KHN, Dara Corrigan, a CMS deputy administrator, said the agency hasn’t told health plans how much they owe because the calculations “have not been finalized.”
Corrigan declined to say when the agency would finish its work. “We have a fiduciary and statutory duty to address improper payments in all of our programs,” she said.
The 90 audits are the only ones CMS has completed over the past decade, a time when Medicare Advantage has grown explosively. Enrollment in the plans more than doubled during that period, passing 28 million in 2022, at a cost to the government of $427 billion.
Seventy-one of the 90 audits uncovered net overpayments, which topped $1,000 per patient on average in 23 audits, according to the government’s records. Humana, one of the largest Medicare Advantage sponsors, had overpayments exceeding that $1,000 average in 10 of 11 audits, according to the records.
CMS paid the remaining plans too little on average, anywhere from $8 to $773 per patient.
Auditors flag overpayments when a patient’s records fail to document that the person had the medical condition the government paid the health plan to treat, or if medical reviewers judge the illness is less severe than claimed.
That happened on average for just over 20% of medical conditions examined over the three-year period; rates of unconfirmed diseases were higher in some plans.
As Medicare Advantage’s popularity among seniors has grown, CMS has fought to keep its audit procedures, and the mounting losses to the government, largely under wraps.
That approach has frustrated both the industry, which has blasted the audit process as “fatally flawed” and hopes to torpedo it, and Medicare advocates, who worry some insurers are getting away with ripping off the government.
“At the end of the day, it’s taxpayer dollars that were spent,” said David Lipschutz, a senior policy attorney with the Center for Medicare Advocacy. “The public deserves more information about that.”
At least three parties, including KHN, have sued CMS under the Freedom of Information Act to shake loose details about the overpayment audits, which CMS calls Risk Adjustment Data Validation, or RADV.
In one case, CMS charged a law firm an advance search fee of $120,000 and then provided next to nothing in return, according to court filings. The law firm filed suit last year, and the case is pending in federal court in Washington, D.C.
KHN sued CMS in September 2019 after the agency failed to respond to a FOIA request for the audits. Under the settlement, CMS agreed to hand over the audit summaries and other documents and pay $63,000 in legal fees to Davis Wright Tremaine, the law firm that represented KHN. CMS did not admit to wrongfully withholding the records.
High Coders
Most of the audited plans fell into what CMS calls a “high coding intensity group.” That means they were among the most aggressive in seeking extra payments for patients they claimed were sicker than average. The government pays the health plans using a formula called a “risk score” that is supposed to render higher rates for sicker patients and lower ones for healthier ones.
But often medical records supplied by the health plans failed to support those claims. Unsupported conditions ranged from diabetes to congestive heart failure.
Overall, average overpayments to health plans ranged from a low of $10 to a high of $5,888 per patient collected by Touchstone Health HMO, a New York health plan whose contract was terminated “by mutual consent” in 2015, according to CMS records.
Most of the audited health plans had 10,000 members or more, which sharply boosts the overpayment amount when the rates are extrapolated.
In all, the plans received $22.5 million in overpayments, though these were offset by underpayments of $10.5 million.
Auditors scrutinize 30 contracts a year, a small sample of about 1,000 Medicare Advantage contracts nationwide.
UnitedHealthcare and Humana, the two biggest Medicare Advantage insurers, accounted for 26 of the 90 contract audits over the three years.
Eight audits of UnitedHealthcare plans found overpayments, while seven others found the government had underpaid.
UnitedHealthcare spokesperson Heather Soule said the company welcomes “the program oversight that RADV audits provide.” But she said the audit process needs to compare Medicare Advantage to original Medicare to provide a “complete picture” of overpayments. “Three years ago we made a recommendation to CMS suggesting that they conduct RADV audits on every plan, every year,” Soule said.
Humana’s 11 audits with overpayments included plans in Florida and Puerto Rico that CMS had audited twice in three years.
The Florida Humana plan also was the target of an unrelated audit in April 2021 by the Health and Human Services inspector general. That audit, which covered billings in 2015, concluded Humana improperly collected nearly $200 million that year by overstating how sick some patients were. Officials have yet to recoup any of that money, either.
In an email, Humana spokesperson Jahna Lindsay-Jones called the CMS audit findings “preliminary” and noted they were based on a sampling of years-old claims.
“While we continue to have substantive concerns with how CMS audits are conducted, Humana remains committed to working closely with regulators to improve the Medicare Advantage program in ways that increase seniors’ access to high-quality, lower cost care,” she wrote.
Billing Showdown
Results of the 90 audits, though years old, mirror more recent findings of a slew of other government reports and whistleblower lawsuits alleging that Medicare Advantage plans routinely have inflated patient risk scores to overcharge the government by billions of dollars.
Brian Murphy, an expert in medical record documentation, said collectively the reviews show that the problem is “absolutely endemic” in the industry.
Auditors are finding the same inflated charges “over and over again,” he said, adding: “I don’t think there is enough oversight.”
When it comes to getting money back from the health plans, extrapolation is the big sticking point.
Although extrapolation is routinely used as a tool in most Medicare audits, CMS officials have never applied it to Medicare Advantage audits because of fierce opposition from the insurance industry.
“While this data is more than a decade old, more recent research demonstrates Medicare Advantage’s affordability and responsible stewardship of Medicare dollars,” said Mary Beth Donahue, president of the Better Medicare Alliance, a group that advocates for Medicare Advantage. She said the industry “delivers better care and better outcomes” for patients.
But critics argue that CMS audits only a tiny percentage of Medicare Advantage contracts nationwide and should do more to protect tax dollars.
Doolittle, the former CMS official, said the agency needs to “start keeping up with the times and doing these audits on an annual basis and extrapolating the results.”
But Kathy Poppitt, a Texas health care attorney, questioned the fairness of demanding huge refunds from insurers so many years later. “The health plans are going to fight tooth and nail and not make this easy for CMS,” she said.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Republished with permission from KHN
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
With the flu season ramping at unprecedented rates, and a new surge of RSV coming when COVID-19 numbers are rising again, the topic of a healthcare surge emergency is back in the headlines. What the New York Times is calling a “Tripledemic” is threatening to overwhelm providers and hospitals yet again. During the peak of the pandemic, hospitals experienced a surge in demand for physical resources and personnel that lasted nearly two years. And just when things started to adjust back to some recognizable norms, the question is again on everyone’s mind: “How do we tackle a surge?”
According to Shereef Elnahal, MD, president and CEO of University Hospital and former Commissioner of New Jersey’s Department of Health, hospitals and health systems often lose money during their peak seasons. Supply shortages are largely due to the fact that most hospitals use a fee-for-service payment model.
Hospitals that charge on a fee-for-service basis are paid based on the volume of patients they treat, not the quality of patient outcomes. Because of this, hospitals usually operate at full capacity in order to reap the greatest rewards. When patient volumes rise during peak seasons, however, hospitals have little margin for error.
According to static payment rates for inpatient care, hospitals may struggle with seasonal demand. In order to keep up with surges, health systems may have to hire more staff or order more supplies, which leads to increased expenses despite no increase in revenue.
During flu season, primary care physicians often augment their workforce by up to 30 percent and still face financial challenges and capacity limitations. Across all healthcare facilities, staffing shortages have become worse as a result of the COVID-19 pandemic, which increased the need for healthcare professionals.
Rather than relying on simply adding more headcount, health systems needa model that can easily adjust healthcare delivery to fit any situation, including increased patient capacity and pandemic surges. Creating a value-based payment model may give health systems more flexibility when dealing with demand surges.
According to the quality of care, providers are compensated using value-based payment models, not the quantity. This approach may inspire health systems to improve staffing procedures. In contrast to dividing physicians’ time in a way that will lead to the highest number of completed services, health systems might focus on patient needs and health outcomes in order to address them.
Physicians using a value-based model are less likely to refer patients to specialty care facilities if those referrals are not medically beneficial.
Because of Maryland’s value-based all-payer model, which reimburses hospitals using global budgets for inpatient episodes of care, hospitals in the state were able to manage the influx of patients during the pandemic far better than neighboring states with different models.
A study from JAMA Network Open noted that the all-payer model also decreased surgical spending and surgical complications. Providers can save resources and supplies for busy periods if they are reimbursed based on outcomes rather than quantity of services.
Patients may be able to avoid expensive hospital stays, saving staff time and resources, if they have access to healthcare services at home. Hospitalization rates may also be lowered by using home-based primary care services.
In addition, health systems could leverage telehealth services to assess patients and determine if an in-person visit is required. According to the authors, telehealth use could improve access to care and save hospitals money.
Patients may also be able to manage their acute conditions from home using remote patient monitoring technology.
Surges can also be a contributing factor to physician burnout. That is why reducing physician workload (blog post) should be a part of hospitals’ strategy of dealing with patient surges.
The DoctusTech Mobile App is based on our successful HCC education and retention strategy, which relies on clinical vignettes customized to the clinicians’ weaknesses and strengths, which are sent to their mobile phones every week. With an engagement rate of 90%, DoctusTech App results far exceed any other learning tool, technology, or strategy.
After using the app for HCC coding education, clinician RAF accuracy is consistently increased based on the learning data.
What methods does the app use to accomplish this?
Our app gamifies the learning experience, connects clinicians with one another, allows them to compete for real prizes, and provides administrative support. In addition, the most advanced HCC code search tool in the world is available. Clinicians earn 25 CME hours every year as they learn HCC coding in a non-boring app!
Audits are no longer just for large payors, provider groups are feeling the pressure of rising compliance audits, and the playing field is complicated to negotiate. Some of this may seem unfair, but with the cost of medical fraud on the rise, the DOJ, CMS, OIG, HMS and all the other initials are not going to let up any time soon, if ever.
The DOJ sued Cigna in October, the Supreme Court refused to intervene on behalf of Molina Healthcare’s whistle-blower case, and more negative audit and antitrust cases are appearing daily.. You may be doing your best but that is no defence in an audit. The only things that matter are facts, documentation, accuracy, and pure compliance. Practicing medicine is an art, but documenting is a strict science, and anything less than precise documentation may result in poor audit outcomes and your company’s name up next in the headlines.
The DOJ is relentless, but not unpredictable. It turns out, they consistently target the same set of codes in nearly every suit. Apparently, the “low-hanging fruit” can be bucketed into four simple categories: Acute coded as chronic; Lack of clinical accuracy or supporting documentation (MEAT Criteria); and Diagnosing without changing the plan of care.
We’ve pulled together a list of “The Usual Suspects” – HCC codes that appear most frequently in DOJ audits, and married the specific codes with strategies to both find them in your EMR and avoid them in your coding. Access the most common offenders in our free report.
Back in 2004, CMS introduced HCC coding as a tool to help estimate Medicare costs. Today, HCC coding us used across Medicare Advantage plans, the Medicare Shared Savings Program, Medicaid, and private health plans – all deploying a variation of the risk adjustment model in order to quantify the upcoming cost of care for their member population, and as a mechanism of submitting that care need to CMS for payment. And yet, the question comes up more often than you may think: “What is HCC Coding?”
Even in the value-based care space, there is confusion around HCC coding, which ICD10 codes risk adjust, and how to diagnose and document accurately and specifically. So if you’re moving from fee-for-service into VBC, taking on risk for the first time, or a veteran at HCC coding for VBC, this article will clarify much of the confusion and simplify what HCC coding is, why it matters, how it is used and what the future holds for HCC and VBC.
Do Doctors Know HCC Coding?
First, clinicians typically have a good working knowledge of ICD-10 codes. And every org has their lookup functions baked into the EMR. However, not only do most ICD-10 codes not work as HCC codes, many of the traditional ways of diagnosing in the fee-for-service world are turned on their heads in VBC. So knowing or having access to ICD-10 codes is not actually that much of an advantage when learning HCC coding. In fact, in some cases, that knowledge can be a liability.
Knowing the code to document diabetes is great, but using that same basic E11.9 that you’re used to is not helpful when diagnosing in a risk model. You need to dig into the complications, the severity of the disease state, and both diagnose and document with high specificity in order to treat and afford to treat the full complications of the disease. If you under-diagnose, you will likely under-treat, and risk an avoidable hospitalization, the risks to the patient and the costs notwithstanding. So in the case of diabetes, a quick check of the toes could yield a missed diagnosis that is critical to the patient’s care as well as accurate RAF and adequate capitation.
What are HCC Codes?
Hierarchical Condition Categories – as the name implies, the categories relate to a hierarchy of of conditions, and it all works together as an efficient sort function to calculate the risk that the patient’s will be expensive. Think about it like this: A patient with mild diabetes as unlikely to end up in the ER due to their disease, so basic diabetes does not risk adjust; whereas a patient with severe diabetes with complex circulatory symptoms that have already led to amputation of one toe is at extremely high risk of ending up in the ER, and they will require a lot of personal and intense care to keep them out of the hospital. And care costs money, so risk and care are nearly synonymous. A higher risk diagnosis gets an HCC code with a higher risk adjustment score, which adds a higher multiplier to the capitation of that patient – meaning the government pays more dollars a month to maintain that disease and help that patient stay out of the hospital.
How do clinicians use HCC coding?
The primary use of HCC codes is to document new chronic condition diagnoses, and recapture chronic conditions being treated, and communicate those diagnoses to Payors and CMS in order to receive capitated payments.
How do HCC codes translate to revenue?
The payment model is obviously vastly different from the traditional fee-for-service (FFS) format where actions are performed, justified, transmitted as CPC codes and reimbursed by payors and/or CMS. In the VBC model, a patient is diagnosed with a specific chronic condition, that condition is documented and coded based on hierarchical condition categories that adjust the risk associated with keeping that patient healthy and out of the hospital. By taking on that risk, the plan or provider group is agreeing that, if given a reasonable amount of money, they will be able to maintain the health of that patient. That money directly ties back to the HCC codes documented, and is paid on a capitated model, with a certain dollar amount paid per-member per-month (PMPM). Those payments allow the overall organization to provide excellent care to the entire patient population, paying extra attention to those whose disease states have reached a complexity where significant resources are required to maintain optimal health. Whether for-profit or non-profit, the organization providing care will financially benefit from accurate diagnosis coding and aggressively proactive care.
How does HCC coding help doctors get paid?
When done correctly, practicing medicine in a Value-Based Care arrangement means more time for doctors, less administrative burden, less burnout and more time to spend per-patient. Smaller panels, and more help treating patients mean that a good doctor can provide truly life-changing care to patients without over-working or over-coding. And by practicing good medicine with proper HCC documentation, you will find your organization flourishing and your patient outcomes improving – all while actually decreasing the overall cost of healthcare. Sure, there is no such thing as a perfect system, but this is as close as we can get in today’s environment. And with an eye to continuous improvement, good coding and good care puts your organization squarely on the path.
How does HCC coding translate to patient care?
You cannot treat what you do not diagnose. And if you diagnose with an eye to changing the trajectory of the patient’s care plan, you are practicing good medicine. To diagnose without proper documentation denies the patient the care that comes from critical revenue. And to document without care is, simply put, fraud. So diagnose with high specificity and proper documentation to ensure that your clinic can afford to provide the kind and quantity of care that will keep your VBC patients out of the hospital. Better HCC coding = better care.
How long does it take to learn HCC coding?
Depending on the tools used for teaching and learning, it can be a years-long process fraught with frustration and difficulty – OR – it can be a simple weekly check-in on an app that uses modern learning methodologies to make mastery quick and easy.
How does HCC coding relate to compliance audits?
The number of compliance audits of provider groups has been steadily rising. The DOJ launches new lawsuits against both large payors and smaller provider groups with increasing penalties. And the Supreme Court has refused to step in and ease the pressure, letting whistle-blower cases proceed unchecked. Clinicians are doing their best, but that is no defense in an audit – the only thing that matters is facts, documentation, accuracy and pure compliance.
Practicing healthcare is an art, but documenting is a strict science, and anything less than accurate documentation vigorously maintained will likely result in negative audit outcomes and your group’s name landing in next month’s headlines.
CMS and DOJ have been increasingly scrutinizing payor strategies and billing patterns as it pertains to Hierarchical Condition Categories (HCCs). As more and more physician groups take on risk in the VBC models, it is imperative that physician groups do not make the same mistakes as their payor partners (intentionally or not).
Some of the most common offenses are fairly simple to avoid. But as we all know, simple does not mean easy. In fact, achieving simplicity can be far more difficult than creating complexity – which is what happens most of the time. A simple solution requires tremendous discipline.
HCC coding for acute conditions
As a rule of thumb, an acute code should not repeat 2 years in a row for a specific patient. And usually, even the first year is inaccurate. Acute heart attack is one of the most common errors penalized by CMS and the DOJ. One reason for this is misunderstanding how to document “history of heart attack” vs “heart attack.” Another version is chronic conditions that have been mis-coded as acute. There is a very short distance between upcoding and practicing good medicine.
It is sometimes appropriate to use these within the year where the acute event occurred, but the following year you must diagnose and document a different code. A third of the most common acute condition dinged by CMS is the combination of #1 & #2 – Acute Stroke and Acute Heart Attack.
Lack of clinical accuracy or supporting documentation – Medical diagnoses are complex and sometimes exist in the gray area between possibilities – but coding and compliance are hard rules. Picking the wrong code. Commonly misused diagnoses. While RADV audits are routinely looking for MEAT criteria, they’re not looking for clinical criteria or diagnostic accuracy.
Commonly misrepresented diagnoses: The exact criteria can be confusing even though the treatment can be the same for mild, moderate, and severe forms of certain diseases. Misrepresentation of the severity can result in overpayment from CMS, and legal and financial penalties – not to mention the obvious ethical concerns.
What is HCC Coding Without Plan of Care?
Now that a doctor has diagnosed a chronic condition, what is the plan to treat or manage the disease? A diagnosis that does not demonstrate a direct and deliberate impact on the plan of care is almost always incorrect at best, and in an audit, illegal. Diagnosing and documenting should function as a mechanism of providing care; documenting to document is never correct. So be on the lookout for conditions diagnosed and codes submitted that do not impact the plan of care. These are often targeted by CMS, both in OIG compliance audits and RADV audits.
How is HCC Coding improved by Education and 1-on-1 coaching?
Build a culture that connects patient care to diagnostic specificity and accuracy in coding and documentation. No doctor wants the business managers coming down from their offices, clipboard in hand, scolding about how code capture and RAF scores impact revenue. But every clinician understands the need to improve care and decrease cost. So start there – in VBC, practicing good medicine and providing better care starts at accurate diagnosis right through to rigorous documentation.
Documentation enables treatment, funds resources to provide care, ensures better health outcomes for patients and actually lessens clinician workload – when done correctly. Chart audits do not have to be brutal, they can be helpful, asking clinicians how a particular diagnosis changes the care trajectory, and helping document for maximum patient benefit. Internal meetings should focus on coding as care. And manual chart reviews should be performed by medical doctors to give timely 1-to-1 feedback. If this is done, the last error on the OIG’s list of usual suspects will go down:
How does HCC coding impact clinician workload?
It can go either way – with increased coding requirements becoming a burden, both to learn in boring seminars and to chase down in chart reviews. But with modern advanced app-based learning tools like DoctusTech, clinicians can master HCC coding in as little time as 5 minutes per week.
What is HCC coding to the OIG?
The Office of Inspector General of the Department of Health and Human Services is at the forefront of auditing healthcare fraud, and recommending action from the DOJ.
From OIG: Since its 1976 establishment, the Office of Inspector General (OIG) has been at the forefront of the Nation’s efforts to fight waste, fraud and abuse and to improving the efficiency of Medicare, Medicaid and more than 100 other Department of Health & Human Services (HHS) programs.
In today’s healthcare landscape, the OIG is finding value-based care to be a target-rich environment, with special focus placed on Medicare Advantage programs, as these allow a small action (documenting a chronic condition that does not actually exist) to multiply into a year of capitated payments to an organization. The simple act of up-coding a condition into something more complex than it should be or over-coding by documenting a chronic condition that does not exist results in thousands of dollars per year in fraudulent overpayments.
What is HCC coding to the DOJ?
While the Department of Justice is not directly concerned with healthcare, they are very concerned about medical fraud, which defrauds the government’s medicare programs, and in extension, the American people. Most often, the DOJ takes on whistleblower cases, where an individual from inside an organization shares insider information regarding acts of upcoding or overcoding that are both large and systemic. These whistleblowers stand to profit significant sums, at times earning up to 20% of the total settlement. And with the recent Sutter case settling at $90,000,000, the whistleblower could potentially take home $18 Million. The False Claims Act ensures that the federal government has a means of penalizing organizations and individuals who, through filing false claims, defraud the government. While this law has been in place since the 1800s, it is getting renewed attention as the DOJ discovers millions of dollars in false claims specifically in Medicare Advantage programs, as these allow an organization to bill CMS with very little scrutiny or oversight.
Top mis-used HCC codes
We address this in a report, feel free to request it HERE.
Also, codes most found in unlinked chart reviews, and subject to RADV audits are detailed in our white paper, found HERE.
What are the requirements for HCC coding documentation?
Generally referred to as the MEAT Criteria, here are the four things you must have to document an chronic condition with an HCC code:
M = Monitoring by ordering or referencing labs, imaging studies or other tests
E = Evaluation with a targeted part of the physical examination specific to a certain diagnosis
A = Assessment of the status, progression or severity of the diagnosis
T = Treatment with medication, surgery, lifestyle modification, or referral to a specialist.
What are the best HCC coding tools?
What apps are available for learning, search, lookup, documentation? This may be a bit of a self-promoting softball, but if you haven’t checked out the DoctusTech app by now, you really should. Make time with a member of our team to see if the DT app is right for your team. Demo DoctusTech today.
What is the best way to change physician behavior around HCC coding
Notes and insights from a study published by AJMC on how to change physician behavior. “The authors evaluated methods for implementing clinical research and guidelines, in order to change physician practice patterns, in surgical and general practice. They evaluated the effectiveness of different implementation methods.”
And as we have demonstrated through successful behavior change in physicians using our HCC coding education app, the most common solutions aren’t the most effective when it comes to ongoing positive change in physician behavior. Want to learn how to change physician behavior? Let’s dig a little deeper into a review of reviews, revealing some hard truths.
We’ve been saying for years, lectures do not work. Emails do not work. If you want to know how to change physician behavior on HCC coding, don’t take our word for it. The American Journal of Managed Care released a systematic review evaluating fourteen medical reviews in an effort to understand which interventions are most effective in changing physician behavior for the better and improving patient outcomes.
It is evident from their publication that the methods of intervention most commonly deployed in teaching doctors HCC coding are rarely able to create lasting change in physician behavior.
What is the best tool inside the EMR?
The DoctusTech Patient Data Analysis Platform (PDAP) is the premier tool for Value-Based Care, living inside the EMR and helping clinicians find and use the best HCC codes, track and manage care associated with chronic diagnoses, and learn which codes to use for which patients – all while reducing clinician workload. It helps readdress conditions diagnosed last year, significantly improving recapture rates. And it helps administrators see into the data by clinician, patient, clinic or by codes. Learn how the DoctusTech PDAP can help your patients and your doctors live happier, healthier lives. Demo DoctusTech today.
The Department of Justice has filed a new lawsuit against Cigna for overcharging the federal government by purposefully inflating how sick its Medicare Advantage members are.
Federal prosecutors previously declined to intervene in this whistleblower case, but have now seemed to change their minds about it.
The lawsuit brings up a very important point: Medicare fraud is a widespread practice. This lawsuit has just been another push by the government to crack down on insurers who exaggerate enrollees’ conditions in order to get more money from Medicare.
Over the past 2 years, the DOJ has joined separate, similar lawsuits against Medicare Advantage plans run by Kaiser Permanente and Elevance (formerly known as Anthem) and settled cases with several other similar organizations.
The lawsuit focuses on risk adjustment
The lawsuit focuses on risk adjustment – a process in Medicare that pays insurers more if patients are sicker than average. Some patients are assigned a higher ‘risk’ score’ than others due to conditions like diabetes, heart disease, etc.
Risk adjustment is a program to encourage insurers to cover people who might be considered a higher risk, even though they might be healthy. However, the current risk adjustment program also gives incentives to insurance companies and their vendors. They may prioritize coding diagnoses and bundling them together depending on your age or other factors.
The lawsuit specifically claims Cigna abused in-home assessments, where nurses and other clinicians go into a patient’s home and conduct health screenings.
The DOJ said Cigna’s home visits were designed to generate revenue for Cigna, not to provide medical care or treatment. They cited several instances in which people were diagnosed with things like rheumatoid arthritis but never received the blood tests they needed to confirm the diagnosis.
The practice of adding more conditions without verifying their accuracy is illegal. Every year, insurers have to attest to Medicare that they are following the rules and practices set by them. The overall practice is extremely profitable for Medicare Advantage insurers – potential profits could be thousands of dollars per year for just one patient.
The lawsuit by the DoJ is a cautionary tale on why it is imperative and critical for healthcare service providers to make their doctors compliant by coding accurately, documenting everything and providing proper justification.
How DoctusTech Helps Protect Against Actions Like This
HCC Coding Education in an app: DoctusTech helps train clinicians on proper VBC diagnosis requirements in a fun and engaging app. Through clinical vignettes and gamification, doctors learn quickly and accurately how to diagnose for risk, which HCC codes to use for what, and how to meet MEAT standards on all documentation. Learn how the DoctusTech app can help keep your team compliant today.
HCC Coding Implementation In Your EMR
DoctusTech Patient Data Analytics Platform: The PDAP sits inside your EMR and provides a simple pathway to capturing unique accurate diagnosis codes, recapturing appropriate past codes, and document appropriate MEAT standards were met to ensure highest data integrity and audit preparedness. To assist admins manage recapture codes across the organization, the integrated solution provides an Admin Portal that lists the recapture rates across clinic, provider, and patient level. This ensures that you have all the necessary information at your fingertips on clinics, providers, and patients as it relates to HCC coding, documentation, accuracy, and more.
Nearly 60 percent of health systems are looking to move into risk-based Medicare Advantage programmes in the coming year, according to the Healthcare Financial Management Association (HFMA) executive survey for Guidehouse Health Insights. This is a 14 percent increase from the June 2019 Guidehouse/HFMA analysis, Guidehouse said.
According to the survey of over 100 CFOs and finance and managed care executives from provider organizations, Medicare Advantage isn’t the only line of business that will take on risk in 2022.
More than half of executives (52% ) plan to increase risk-based payment or capitation in their commercial lines of business, while 49% anticipate taking on more risk or capitation through Medicare alternative payment models. In other words, health systems expect risk-based payment to both increase and diversify across business lines.
More than one-third of executives believe that risk-based payments will increase in managed Medicaid, 33 percent in direct-to-employer arrangements, and 12 percent “otherwise.”
According to Guidehouse Partner Richard Bajner, we are seeing increased interest from providers to own the premium dollar through risk-based arrangements. Large payers, on the other hand, have been investing directly in primary care assets to gain control over the flow of care and better manage services delivered to members, increasing the need for payors and providers to collaborate closely on market strategies, according to the press release.
According to Guidehouse, payviders, the value-based partnership between a payers and provider, can employ risk-based contracting between payors and providers, provider-sponsored health plans, joint ventures, and payor-new-entrant partnerships to encourage the adoption of employer-sponsored health plans.
Payvider models, however, are not suitable for all markets, the study found. Furthermore, a recent survey discovered that health systems faced substantial challenges in establishing strategic partnerships with payors, a crucial element of payvider success.
According to the survey, 50% of executives cited pursuing payor models or increased risk, capitation, or joint venture arrangements as their top external challenge. This challenge was chosen over local competition (21%), legal/trust issues with payors (10%), other (9%), new entrants/disruptors (6%), and price transparency compliance (4%).
Despite the challenges with fee-for-service, risk-based revenue has stalled.
In addition, 52 percent of executives said that vertically integrated health plans, such as UnitedHealth Group, were a major barrier to success with pay-for-performance models in their market.
According to the survey, 36% of executives see data and technology costs, integrity, reporting, and insights as their greatest internal hurdle to pursuing payvider models or increasing risk, capitation, or joint venture arrangements. Internally, health systems are having trouble with data and technology.
23 percent of those surveyed cited lack of collaborative payor/provider partners as the biggest challenge to achieving quality or cost outcomes, while 13 percent said scale, 10 percent said difficulty achieving quality or cost outcomes, and 9 percent said leadership alignment or support was the most challenging aspect (Klaphake, 2018).
Despite taking a risk-based payment approach, most health systems are still developing the required capabilities in-house. Thirty percent of executives said their organisation is collaborating with a health plan, 21 percent are outsourcing capabilities, and 7 percent are sourcing capabilities from other healthcare organisations. Around half (51 percent) believe the abilities are being developed in-house.
According to the American Journal of Managed Care (AJMC), the least effective method for continuing medical education (CME) for clinicians is distributing printed materials: emails, PDFs, flyers, email blasts, and so on. Many medical professionals believe that clinician education should be concerned with encouraging continuous development rather than simply raising consciousness. What, then, are the most effective strategies for accomplishing the goal of both informing and changing clinician behavior?
The AJMC says that the methods of intervention most commonly deployed in teaching doctors HCC coding are those same methods determined to rarely create lasting change in physician behavior (classroom lectures, emails, PDFs, flyers, email blasts). So most frequently utilized modes of learning are clearly out.
“When you’re seeing patients, you remember the questions, and you remember what you need to ask the patients.” – Dr. Villaplana-Canals, Florida, DoctusTech App User
Both the AJMC and common sense agree that active education methods and multifaceted interventions are the most effective when it comes to educating and changing physician behavior. The DoctusTech mobile app provides active education and multifaceted interventions through clinical vignettes. In other words, our app helps you achieve your desired outcomes – as a physician, or as an operator for your physicians. In fact, we provide the most effective intervention methods, demonstrated by consistently better outcomes.
How?
Learning in the app is driven by clinical vignettes, placing clinicians in a real-life patient scenario, presented with symptoms and facts, and then asked questions about diagnosis and documentation, all in an effort to alter the method of diagnosing from the fee-for-service approach most physicians were educated in to a value-based care system, in which chronic conditions are diagnosed in a very specific manner, with an eye to risk and outcomes. By including any and all information about the diagnosis that impacts risk adjustment in the diagnosis, clinicians learn to both diagnose and document those diagnoses with supporting information in the chart.
“The mobile app is wonderful, in that it’s a clinical vignette – it’s what is literally in front of their face, and it gets them thinking.” – Teresa, Director of Clinical Documentation Improvement
For clinicians, behavior change is accomplished through learning in clinical vignettes with the DoctusTech mobile app. Doctors learn more deeply and permanently about diagnostic procedures and proper documentation by sitting through a clinical vignette. The socratic method is a highly regarded teaching tool as well as being one of the most commonly used teaching strategies in medical school. The socratic approach is utilised by medical students as they learn by questioning in clinical vignettes. It is fitting, therefore, that they will gain a new store of knowledge through clinical vignettes.
“It does reinforce for us something that, although most doctors use a problem list, most of the problem lists … ended up being too long, too nonspecific, and very unwieldy to use in the clinic. The training taught me to make sure you have the linkages and causations clearly laid out.” – Dr Joseph Bateman, Medical Director, Christ Hospital, DoctusTech App User
Clinicians can justify the RAF score impact of those diagnoses by supporting them with appropriate documentation that meets the MEET criteria. When there is an audit (When, not If), their charts are proper and in order, and their patients are well cared for.
Rather than diagnosing “diabetes” a DoctusTech educated physician would instead test for complications and diagnose a specific disease condition, accurately reflecting the capitated payments for that person’s care. The behaviour change comes from switching from one ICD-10 code that doesn’t risk adjust to a more specific diagnosis, using a different ICD-10 code that does adjust the risk of that patient and accurately reflects the change in capitated payments for their care.
Book a demo today, and experience DoctusTech Mobile App’s transformative teaching techniques for yourself!
Value-Based Care is a natural movement toward the benefit of the patient with a reduction in costs by aligning all incentives in the right direction. And as providers make the shift, patients will be encouraged both by the motive behind the transition as well as the improvement in their overall health and the reduction in the costs of their care. Truly, Value-Based Care has the potential to be a significant win-win for patients and providers. And in the end, isn’t that why you spent all those years pursuing your medical training? Value-Based Care is for patients, and for the providers who care for them.
The market is now moving towards building value-based care drivers to all types of patients outside of Medicare Advantage. It’s unlikely a brand new risk model will be born for commercial patients. Therefore, all physicians will need to understand the risk adjustment models and the implications of documentation accuracy for reimbursement.
Why is HCC Coding Important for Value-Based Care?
HCC coding’s importance is less about the impact on revenue and more about the shift towards VBC models, which have consistently shown better clinical outcomes at lower costs. And Hierarchical Condition Category Coding is the language clinicians use to document the diagnoses of chronic conditions and the complications and various disease states that contribute to risk.
Why should doctors care about HCC coding?
Doctors should, first and foremost, care about patients – and they do. But as a mechanism of that care, doctors must diagnose with specificity and document with accuracy in order to provide care and the revenue that affords that care. And HCC coding is how that is done. HCC coding is the documentation foundation for most of the value-based care arrangements used today. With “value-based care” usually being equated with Medicare Advantage, in coming years we believe that VBC will be incorporated into nearly all types of financial models.
HCC coding falls under the broader term of Risk Adjustment (RA) models for prospective payment. These models are designed to determine risk scores and assign a fee according to the patient’s level of risk.
In the Medicare Advantage world, these models use certain demographic and HCC codes to assign a risk score to patients known as an RAF. The assumption is the sicker the patient, the higher the RAF, the more dollars it will take to care for this patient during any given year. Therefore the RAF score of any patient population will determine the prospective payment Medicare disburses.
This prospective payment model based on RAF does 2 things:
Aligns physician incentives. Currently, clinicians make money from taking care of sick patients. The sicker the patient, the more visits, tests, surgeries they have to do, and the more they are reimbursed. In this model, clinicians are incentivized to keep patients healthy and therefore require LESS tests and surgeries.
Spurs clinical innovation the right way. Right now, pharmaceuticals and medical hardware companies are all trying to find ways to treat diseases. The newer the drug or medical device, the more revenue they make. In this model, healthcare groups are incentivized to find new ways of preventing the disease progression from ever needing the latest drug or newest medical surgery equipment.
How can DoctusTech Help?
We provide a modern learning tool for the modern clinician, using gamification, competition, real prizes and administrative oversight to see who is engaging and who needs a little extra help. Also, our app deploys all the subtle nudges and complete with the most advanced HCC code search tool on earth.
DoctusTech helps clinicians learn HCC coding through clinical vignettes in an app that is fun and engaging. Diagnosing with the appropriate HCC code is a critical skill for modern clinicians who care for patients in a value-based care arrangement.
You cannot treat what you do not accurately diagnose, and you cannot afford to treat what you do not appropriately code. Without the correct diagnoses and accurate documentation and coding, caring for patients with complex disease will be unsuccessful, leading to increased avoidable hospitalizations and increased cost to the organization.
In an effort to strengthen its presence in the healthcare technology sector, CVS Health has announced plans to acquire Signify Health for $8 billion. CVS will be acquiring Signify from private equity firm TPG and other Signify shareholders. As a result of this acquisition, CVS will now have access to Signify’s enterprise-grade software solutions for clinical assessment, population health management, care coordination, and patient experience monitoring. Given that Signify is a provider of telemedicine services, the combination of these two companies will give CVC a greater nationwide presence. For example, CVS has 2,300 retail locations where it could place telemedicine kiosks or stations.
And remember, it was just mid-February 2022 that Signify Health announced plans to acquire Caravan Heath for $250 million with $50 million in additional payments depending on performance. This previous merger created one of the nation’s largest provider networks engaging in risk-based payment models. So with the Signify acquisition, CVS will be gaining a considerable share of the Medicare Advantage market, making them one of the biggest players in value-based care.
Why is CVS making this acquisition?
CVS Health’s acquisition of Signify Health will expand its telehealth offerings, increase its reach in the healthcare market, and support its aim to become a one-stop shop for healthcare and health insurance services. Currently, Signify works with approximately 100 health systems and approximately 1,000 physicians. CVS Health currently offers health insurance, retail pharmacy, and other nonclinical services. By bringing Signify on board, CVS Health will be able to connect Signify’s technology with its retail locations to provide customers with a one-stop shop for their healthcare services. CVS Health is also aiming to expand its product offerings to include prescription delivery and doctor’s appointments. If successful, these efforts could further shore up CVS Health’s position in the healthcare market amid an increasingly competitive environment.
What does CVS get from Signify?
With the acquisition of Signify, CVS will gain access to a variety of healthcare products and services. These include enterprise-grade clinical assessment software, population health management services, care coordination software, and patient experience monitoring solutions. The clinical assessment software helps healthcare organizations identify gaps in their care delivery process, while the population health management software enables them to understand their patients’ needs, preferences, and health goals. The care coordination software is used to enhance communication between physicians and patients, while the patient experience monitoring solutions provide real-time insights into patient-facing services.
What does Signify get from this acquisition?
As mentioned above, Signify Health is a telemedicine services provider. It uses AI-powered technology to connect patients with healthcare professionals via virtual consultation. By acquiring Signify Health, CVS Health will be able to expand its telemedicine services to an increased number of customers. CVS Health’s acquisition of Signify Health will increase its reach in the healthcare sector, allowing it to deliver cost-effective and convenient care to a larger number of patients nationwide. In particular, CVS will be able to provide patients with greater access to its pharmacy services.
What does this mean for consumers?
CVS Health’s acquisition of Signify Health could mean greater convenience and lower costs for patients. The health insurer is in the process of integrating Signify’s technology into its own platform. Once this is complete, customers will be able to connect with medical professionals via virtual consultation. These virtual consultations are expected to be offered at CVS Health retail locations or online. Currently, CVS’s customers must travel to its retail locations to access prescription medication and professional health advice. With the Signify acquisition, the health insurer hopes to allow customers to access prescription delivery, health advice, and virtual consultations from a single platform. This is expected to reduce travel costs for customers and enable them to receive quick and accurate health advice from medical professionals.
How will this benefit TPG?
TPG is a private equity firm that has been investing significantly in the healthcare sector over the past decade. Currently, TPG owns approximately a 45% stake in Signify Health. The health insurer’s acquisition of Signify will enable TPG to receive an attractive exit. This exit could come in the form of a cash payout or a partial cash-and-stock transaction. CVS Health’s acquisition of Signify Health is expected to close during the second half of 2019. Once the acquisition is complete, TPG will be able to reap the benefits of its substantial investment in Signify Health.
Final Words: Will we see more healthcare mergers?
CVS Health’s acquisition of Signify Health is the latest in a series of healthcare mergers and acquisitions. For example, in April 2019, CVS Health announced that it would be acquiring Aetna for $69 billion. As the healthcare industry becomes increasingly competitive, we can expect that more mergers and acquisitions will take place. These acquisitions may involve healthcare providers and technology companies or pharmaceutical companies and health insurers. As the healthcare industry undergoes these changes, we can expect to see new healthcare delivery models and solutions emerging. And, with mergers and acquisitions, these solutions can be brought to market faster and at a lower cost.
In December of 2021, the Mayo Clinic published an alarming report: ⅓ of physicians surveyed intended to reduce their work hours – that represents 336,000 doctors. While—and I hope you are sitting down—1 in 5 physicians intended to leave their practice altogether – 20%, or 204,000.
Burnout from workload, COVID-19–related anxiety/depression, and fear of contracting the disease. Now, some of those burdens have certainly eased over the past 10 months – but the prevailing concern of burnout from overwork has hardly abated.
Burnout is a widespread problem in any industry, but the stakes are even higher in healthcare with lives of patients on the line. Quality and safety of care is our top priority and errors or lack of awareness can lead to terrible consequences.
With burnout on the rise and VBC/HCC knowledge requirements continuing to grow, it can feel like there is an impossible riptide in front of today’s clinicians. And with healthcare relentlessly marching in the direction of Value-Based Care, it’s no wonder why new clinicians have a difficult time onboarding. Requiring providers to add HCC coding to their already complex workflow is not only vital to improve the industry, it is increasingly mandated by CMS.
The DoctusTech HCC Coding App is designed with a sole purpose in mind: to reduce clinician workload, and make it easier for them to diagnose, and ultimately, take care of their patients.
The Socratic method, clinical vignettes, and question and answer sessions are the most effective methods for capturing long-term knowledge. This is how doctors were taught in the first place, and this is the best way to do it. With DoctusTech, they can learn HCC coding in the same manner—from other doctors using clinical vignettes—on their own time, requiring only an average of five minutes per week.
The DoctusTech Mobile App is based on our successful HCC education and retention strategy, which relies on clinical vignettes customized to the clinicians’ weaknesses and strengths, which are sent to their mobile phones every week. With an engagement rate of 90%, DoctusTech App results far exceed any other learning tool, technology, or strategy.
After using the app for HCC coding education, clinician RAF accuracy is consistently increased based on the learning data.
What methods does the app use to accomplish this?
Our app gamifies the learning experience, connects clinicians with one another, allows them to compete for real prizes, and provides administrative support. In addition, the most advanced HCC code search tool in the world is available. Clinicians earn 25 CME hours every year as they learn HCC coding in a non-boring app!
If HCC Coding and Physician Burnout are at all on your radar, we’d love to share a solution to both. Better solutions are out there – and they outperform seminars and code-of-the-month email blasts for engagement and results. And they free up your coaches to focus on the 20% that need it the most.
HCC coding improves the quality of patient care and reduces the cost of healthcare. But, like any tool, it’s only effective if the people who use it have it mastered. That’s why it’s so important to provide HCC coding education across your organization. In this article, we will share how DoctusTech helps deploy HCC coding education across your organization.
At DoctusTech, we are always eager to assist healthcare organizations boost HCC training programs. We believe that solving the three shortcomings of risk adjustment—the data gap, the workflow gap, and the knowledge gap—is critical. Most available solutions address only the data or workflow gaps. However, if your clinicians don’t have the right knowledge, you won’t obtain the outcomes you desire no matter what you do to resolve the data and workflow issues. We strongly believe that if you resolve HCC coding knowledge challenges, your data and workflow issues will be resolved along the way.
The DoctusTech Mobile App is designed on our successful HCC education and retention strategy that relies on clinical vignettes customized to the clinicians’ strengths and weaknesses, which are sent to their mobile phones every week. With a 90% engagement rate, DoctusTech App results far surpass any other learning tool, technology or strategy.
According to the learning data, we consistently achieve a significant increase in clinician RAF accuracy after they start using the app for HCC coding education.
How does the app achieve this?
Clinicians can use our app to gamify their learning experience, engage with their peers, compete for real prizes, and receive administrative support. Our app also comes with the most sophisticated HCC code search tool available on the planet. In addition, clinicians earn 25 CME hours every year as they learn HCC coding in a non-boring app!
Clinical Vignettes – The secret sauce!
Most doctors who have just graduated from medical school or residency programs know little to nothing about coding for risk adjustment and value-based care. In the past, these clinicians were forced to sit in seminars and learn the correct codes so they could diagnose and document them properly. Every other important medical fact is learned in clinical vignettes, so clinicians have difficulty retaining and applying information learned in boring seminars or email blasts. Simply put, incorporating new HCC codes into daily practice is hard – which is why the DoctusTech HCC coding education app is so vital.
Doctors prefer to learn using the Socratic method, clinical vignettes, and question and answer sessions, because it is the most effective way to capture long-term knowledge gain. This is how they were educated, and this is the best way. DoctusTech enables them to learn HCC coding in the same manner—from other doctors, using clinical vignettes, on their own time, requiring only an average of five minutes per week.
Get in touch to learn more about how DoctusTech helps!
DOJ jumps into yet another False Claims Act lawsuit, this time regarding the Cigna Medicare Advantage Fraud Case. The Department of Justice has joined a False Claims Act lawsuit against Cigna Corp. that alleges the health insurance provider exaggerated the illnesses of its Medicare members in order to receive higher payouts from the federal government.
Cigna Medicare Advantage, a subsidiary of Cigna, was sued in New York federal court in 2017 for defrauding the federal government of $1.4 billion by providing incorrect diagnostic codes from 2012 to 2019. According to the complaint, Cigna defrauded the federal government by providing incorrect diagnostic codes based on health conditions that patients did not have or that were not found in any medical records.
Earlier this month, the court granted the Justice Department’s motion to intervene in the case in particular regarding allegations that Cigna billed Medicare for risk-adjusted payments based on diagnoses that did not include testing, imaging, or other necessary clinical steps.
Cigna Medicare Advantage Fraud Case: a failure to document.
According to the Department of Justice, no Medicare Advantage patients received any treatment for these conditions during home visits or from any other health care provider during 2018. The DOJ initially decided not to join the case in February 2020, but reserved the right to do so. They have until September 30 to file their own case or enter their own complaint. The federal government intervenes less than 25% of whistleblower cases. DOJ joined Medicare Advantage fraud lawsuits against insurance firms UnitedHealth Group and Anthem in 2017 and 2020, respectively, on the same grounds.
According to the Centers for Medicare and Medicaid Services, improper payments from these plans amounted to $16.2 billion in 2020, or 6.8% of all Medicare Advantage.
“I don’t care if the RAF goes up or down, I only care if it’s accurate.”
Dr. Farshid Kazi, Co-Founder, DoctusTech
If an organization is caught over-coding, up-coing, diagnosing conditions that either do not exist or are not supported in the chart, the cost of these errors can be very high. Audits are no longer just for health plans, provider groups like Sutter, Kaiser (and many others) have also been audited by the DOJ and hit with heavy fines.
On the other side of the board are many plans and provider groups that are struggling to diagnose and accurately document chronic conditions that truly do exist and risk adjust, leading to poor performance in VBC contracts and clinician burn-out.
RAF accuracy is achieved through a perfect balance of accurate diagnosis and accurate documentation.
What is Risk Adjustment Factor Scoring
Risk adjustment factors are used to estimate the expected outcome for a patient based on a number of different factors. One important factor is the patient’s age; other factors include socioeconomic status and comorbidities such as chronic illnesses or conditions. Each of these can be scored to give a single risk adjustment factor score.
DoctusTech Enables 30% Rise in RAF Accuracy
How?
We teach clinicians how to think about chronic conditions, improve diagnosis at the point of care, and help documentation and HCC coding – all in a lovable mobile app. And not only do clinicians learn how and what to code, the app is also the most powerful HCC code finder in the palm of your hand. Look up the code through a variety of intuitive queries, by tests that might indicate a diagnosis, and by related conditions – complete with complexities and branch-points to help drill down into greater specificity.
While we cannot share sensitive client data, we can confidently state that a 30% increase in RAF accuracy is well within the normal range for our clients.
DoctusTech Helps by Boosting Clinician Knowledge and Changing Behavior Just by Engaging With a Lovable Mobile App
The app uses the classic learning technique we all grew to know and love in med school: the Socratic method. By posing questions within a clinical vignette, clinicians learn—and remember—how to diagnose, code and document for risk adjustment. By increasing the fund of knowledge around diagnosing chronic conditions, the app improves unique code capture and documentation, boosting RAF accuracy over a very short period of time. After the initial self-assessment, clinicians are only asked to spend about five minutes per week engaged on the app, and behavior change outpaces traditional HCC teaching techniques by a significant margin.
DoctusTech HCC Integrated Platform
Instead of clinicians having to go to various external data sources to gather information, DoctusTech’s HCC integrated platform, HCC 360, consolidates all data sources and presents them to clinicians while they are writing progress notes. Here’s how you can achieve greater RAF accuracy with DoctusTech:
Improve Patient Visits: Based on your patient’s chart, get real-time prompts for questions to ask or labs to consider.
Automate Chart Review: Translate your patient’s chart into HCC code using our A.I. in seconds, based on evidence-based medicine.
Faster Progress Notes: You won’t have to wade through third party portals or paper suspect codes anymore; we bring all sources into your EMR to simplify your life.
As healthcare continues to evolve, it is crucial that providers get educated and improve their skills in using HCC codes. DoctusTech is a revolutionary new way to improve the accuracy of HCC coding by making sure you know exactly how to code each condition. Our simple mobile app that engages clinicians in an easy guided learning experience while they file HCC coding notes. After only five minutes of training, clinicians can quickly and accurately code their own charts and boost the accuracy of their efforts.
Amazon has announced plans to buy OneMedical for $3B. OneMedical is a brick and mortar plus digital healthcare marketplace that operates in several major U.S. markets. The acquisition is Amazon’s latest move in the healthcare sector, and analysts say it could be a sign of bigger things to come. This is not Amazon’s first foray into the healthcare market, but after the Haven experiment closed down, the company has kept a relatively low profile while it tests new business models. In June, Amazon was among several investors that participated in a $35 million funding round for Zscaler, an Austin-based cybersecurity firm that offers an edge security service for cloud networks and internet-facing applications and services. A few months earlier in March, news broke that Amazon had hired former pharmaceutical executive Bernard Jegou as its new vice president of e-commerce strategy and new business development.
And in a very public failure back in 2017, Amazon partnered with Berkshire Hathaway and JPMorgan Chase to form an independent healthcare company called Haven, which it quietly scuttled mid-pandemic, February, 2021. Read on to learn more about how this acquisition could indicate continued interest from Amazon in the healthcare space — or if it is just another pivot from one of its many subsidiaries.
What is OneMedical?
OneMedical is a primary care practice and digital healthcare marketplace that uses technology to reduce healthcare costs and increase convenience for patients. The company has built a network of more than 500,000 doctors and has partnered with health insurance providers across the country to serve more than 3 million members. OneMedical offers a range of services, including access to an online portal for patients and a concierge service for their members. OneMedical’s network of doctors comes from a variety of specialties, including general practice, pediatrics, OB/GYN, and family medicine. OneMedical also offers telemedicine services, including video visits with doctor consultations and prescription refills.
Why might Amazon be buying OneMedical?
While Amazon has not released any details about why it is acquiring OneMedical, analysts say this acquisition may be a sign that the company has larger ambitions in the healthcare sector. Amazon has a track record of acquiring companies in sectors where it sees potential for disruption and then gradually building out its business there. This could be a way for Amazon to expand its e-commerce business into health insurance. It could also be a sign that Amazon wants to become a one-stop shop for healthcare services. Amazon has been experimenting with new business models in the healthcare space for several years now. The partnership with Berkshire Hathaway and JPMorgan Chase formed an independent health company called Haven began with promise, but was quietly closed a few short years later. And in June, news broke that Amazon had participated in a $35 million funding round for Zscaler, an Austin-based cybersecurity firm whose edge security service could help internet-facing applications and services like those that run on Amazon’s AWS platform.
Possible reasons for the acquisition
Analysts say there are a few reasons why Amazon might be interested in acquiring OneMedical. Amazon may be looking to expand its reach into healthcare marketplaces beyond its partnership with Berkshire Hathaway and JPMorgan Chase to form an independent health company called Haven. Acquiring OneMedical could give Amazon a foothold in the digital healthcare space, which has been growing rapidly. Amazon could also be interested in OneMedical’s digital platform for its members. Having an online presence and digital tools for patients and doctors could let Amazon expand into other healthcare sectors, including pharmacy. And Amazon might be interested in the data that OneMedical has on its members, which could be useful for the company’s future endeavors in the healthcare space.
Amazon has bigger plans in healthcare
Analysts say the acquisition of OneMedical could signal Amazon’s intent to become a major player in the healthcare space. It is unclear exactly what the company’s strategy will be, but it is likely that Amazon will focus on improving the customer experience across the healthcare sector. Amazon is no stranger to industries with high-barrier-to-entry business models. The company has made inroads in industries such as grocery and e-commerce, as well as more traditional businesses such as manufacturing and cloud computing. Amazon has long been a disruptive force in the retail sector. The company has reshaped consumer expectations of online shopping and shifted the entire retail landscape in its wake. The company’s foray into digital and bricks-and-mortar retail has been a boon for customers, and it has also provided a boost for shareholders: Amazon’s stock is up almost 102% over the past year.
Value-Based Care and Risk Adjustment
Experts say that Amazon’s involvement may help OneMedical’s risk management as the adoption of more value-based care programmes continues. Most of One Medical’s business has traditionally been generated from charging commercially insured patients per-visit fees, but since the acquisition of Iora last year, Medicare patients are now served, and revenue is captured as a result of savings through risk contracts. According to their website, OneMedical serves scores of Medicare Advantage plans, though patient numbers were not readily available. Scaling value-based care is challenging for providers without extensive data experience. Those in primary care, retail health, and telehealth should be concerned, experts say.
The big question: Is this a pivot or a sign of future intent?
Analysts say Amazon’s acquisition of OneMedical may be a sign that the company is pivoting from its health technology investments, like Zscaler, and looking to establish a more direct presence in the healthcare sector. But it is also possible that Amazon has more ambitious plans in the healthcare space that the acquisition of OneMedical is only the first step in. Whatever Amazon’s end goal is in the healthcare sector, it seems likely that the company will take a slow and methodical approach to growing its business. After all, Amazon has plenty of experience building new businesses from the ground up, and it has a track record of entering new sectors and disrupting existing players with a more customer-friendly approach.
DoctusTech helps clinicians learn HCC coding through clinical vignettes in an app that is fun and engaging. Diagnosing with the appropriate HCC code is a critical skill for modern clinicians who care for patients in a value-based care arrangement. You cannot treat what you do not accurately diagnose, and you cannot afford to treat what you do not appropriately code. Without the correct diagnoses and accurate documentation and coding, caring for patients with complex disease will be unsuccessful, leading to increased avoidable hospitalizations and increased cost to the organization.
And without a tool to get clinicians quickly up to speed on diagnosing for risk at the point of care, coding accurately and documenting correctly, you will be stuck. Stuck in boring seminars that rarely affect lasting behavior change; stuck with missed diagnoses and missed revenue targets; stuck with patients missing out on essential care; stuck with overworked clinicians; stuck.
How do clinicians learn HCC coding?
This is where DoctusTech Helps. We provide a modern learning tool for the modern clinician, using gamification, competition, real prizes and administrative oversight to see who is engaging and who needs a little extra help. Also, our app deploys all the subtle nudges and complete with the most advanced HCC code search tool on earth.
And clinicians earn 25 hours of CME per year, while they learn HCC coding in a non-boring app!
In SCUBA diving, the diver must add just the right amount of weight to maintain perfect positive buoyancy; too much and you will sink, too little and you will bob on the surface like a cork. Risk adjustment in value-based care has some similarities: a successful VBC program will diagnose and treat just the right conditions. Not over-coding, and not under-diagnosing.
Clinicians learn HCC coding better in clinical vignettes
And doctors coming out of medical school and even residency programs know little to nothing about HCC coding and diagnosing for Risk Adjustment and Value-Based Care. Traditionally, these clinicians sit in seminars getting force-fed codes in an effort to teach them how to accurately diagnose and document with the appropriate HCC codes. Unfortunately, this is not how every other vital piece of medical information was learned, so clinicians struggle to retain the information and utilize it in daily practice.
Medical education is all about the Socratic method, question and answer, clinical vignettes. Doctors learned to learn this way, and they prefer it. Which is why DoctusTech helps doctors learn HCC coding the way they like to learn – from other doctors, in clinical vignettes, on their own time, and in an average of 5 minutes per week.
Truly, DoctusTech helps clinicians learn HCC coding. And when clinicians master diagnosing for risk with HCC codes, your whole VBC program improves.
See more ways that DoctusTech Helps:
DoctusTech Helps: Increase RAF Accuracy
DoctusTech Helps: Decrease clinician workload
DoctusTech Helps: Deploy HCC coding education across your org
Why is HCC coding training important? Without proper coding, it is impossible to diagnose accurately, treat effectively, document those diagnoses, or achieve revenue goals. Coding training will help you master the skills you need to properly code patient records, so investing in HCC coding training might be the right move for you! Read on to learn more about HCC coding training!
What is HCC coding?
Hierarchical condition category (HCC) coding was created to estimate future health care costs for patients. The Centers for Medicare & Medicaid Services (CMS) HCC model was established in 2004 and is increasingly being used as value-based care gains traction. The HCC model relies on ICD-10-CM coding to assign patients risk scores based on their medical condition. Each condition is associated with an ICD-10-CM code. For example, a patient with few serious health problems is likely to have average health care costs for a specific period of time. Patients with many chronic conditions, however, are more likely to have higher health care utilization and costs.
Why is HCC coding training so important?
As we mentioned above, proper healthcare coding is important for a number of reasons. However, even the best healthcare providers cannot properly code without the right training. If you are new to the healthcare industry, you will need training to learn the coding system and understand the complexities of accurate diagnosis and documentation. If you have been in the industry for a few years but have not kept up with the latest coding trends, you may also need training to refresh your skills. Whatever your situation, it is important to take the time to invest in HCC coding training. This training will help you master the terminology and coding systems that are used in the healthcare industry. It will also help you learn how to properly diagnose and document for better patient care.
Which platforms and tools are effective?
HCC coding training can be delivered in a variety of ways. Depending on which courses you decide to take, you may be able to access them online or on your mobile device. Most HCC coding training courses will include videos, interactive activities, and practice tests. These tools can make learning easier and more effective. They can also help you retain the information you learn effectively. If you are looking for HCC coding training, it is important to find a platform or a course that fits your learning style and skill level. If you are new to the industry, you may want to take a beginner’s course. If you have been in the industry for a few years and just want to refresh your skills, you might want to take an intermediate or advanced course.
3 Things to include in your training plan
When you are ready to start your HCC coding training, it is important to make sure you have a plan in place. This will help you stay motivated and on track and make sure you finish before the course’s deadline. There are a few things you should definitely include in your plan.
Set specific goals
Before you begin coding training, you should sit down and set some specific goals for your course. What do you hope to achieve by the end of your training? By setting specific goals, you will know what you are working towards and have something to motivate you.
Set a schedule
It is important to set a schedule and stick to it. This will help you stay motivated and make sure you do not get overwhelmed by the coursework. Make sure you allot enough time for studying each week and do not try to cram. A healthy pace is achievable at 5 minutes per week, if you have the right tools.
Stay focused
Finally, during your coding training, it is important to keep your eye on the prize. While coding is interesting and can be complex, you do not want to get so involved that you lose sight of your goal. Stick to your schedule, do not try to push yourself too hard and you will be on track to finish in time.
Get Started Today
Doctus Tech is the best way for clinicians like yourself to start learning to diagnose with HCC codes. Benchmark yourself with other clinicians, identify your team’s knowledge gaps and benefit from a 30% increase in RAF accuracy. Sign up for a 14-day trial now!
Risk adjustment coding is a vital part of any managed care organization. It helps to ensure that patients are appropriately diagnosed and documented accurately according to risk level, which in turn allows the organization to receive appropriate capitated payments to provide all the care needed to reduce avoidable hospitalizations and achieve maximum health. And regardless of how challenging and time-consuming it can be to implement, getting it right is vital on many levels. Diagnosing and coding for risk can be tricky.
It is not always obvious how complex and risky a condition is, especially because some patients are at higher risk than others for diseases like depression or schizophrenia, but many conditions can be difficult to diagnose. Those who appear low-risk might actually be high-risk, once you dig deeper into the specific diagnosis details. There are thousands of potential codes and conditions to diagnose that can be used to determine risks. There is no perfect formula for every managed care organization; you have to find protocols for training and improvement that work best for your clinicians and operators. Let’s take a look at some of the challenges involved in risk adjustment coding and how to get it right.
Determining risk is difficult
When implementing a risk adjustment program, make sure you have a team on hand with strong coding and data management skills. These team members should be able to look at each patient record and determine both the conditions that have been diagnosed as well as the documentation criteria to be applied to that patient in the chart. This team will be responsible for determining and documenting diagnoses that correlate to the risk level of each patient. This task can be difficult since mastering HCC coding for risk adjustment requires a lot of learning and is often different than standard ICD-10 coding. But there are modern tools for mastering this, so do not lose hope.
Risk adjustment requires a lot of data
Risk adjustment also requires a lot of data. The more information you have about each patient, the better you are able to diagnose based on their true conditions and related risk. If you do not have enough data about a patient, or lack consistent data throughout the lifetime of a patient relationship, you will have a hard time determining their true risk level.
For example: Patient A has been a patient for 10 years, and Patient B has been a patient for 2 years. If you’re trying to diagnose the patients, you’ll have to take into account their lifelong risk factors and current health status. This includes things like socioeconomic status, age, family history of certain diseases, how much they smoke, and more. If you have a few years of data points on Patient A, and only a few months of data points on Patient B, you’ll be able to diagnose Patient A more accurately.
Coding errors are common
Coding errors are common in risk adjustment, but they can be avoided with consistent training, accountability, strict internal audit procedures, and improved clinician buy-in. Coding errors can lead to overcharging or undercharging the CMS, resulting in either missed earnings or painful charge-backs. Coding errors can be caused by a number of different factors. For example, mistakes could be made when determining which diagnoses apply to patients, which codes to use for the diagnoses, or what to document to justify the diagnosis in the chart. Diagnoses require clear communication as well as consistent documentation on all patient records.
It is only going to get harder.
The bad news is that risk adjustment is only going to get harder. New technologies like AI, voice recognition, and machine learning are changing the way health care providers analyze and manage data. While these technologies will make many aspects of coding and managing data easier, they will also make it more complex by introducing even more variables and data points to consider. So while risk adjustment could be more challenging, there are tools available that simplify the process both in training and inside the EMR.
Risk adjustment is vital, because it ultimately determines what type of care an individual patient needs and how much risk the organization is taking on, managing that care. It is important to ensure that your organization is accurately diagnosing and documenting so that patients stay healthy and your organization has the needed revenue to manage their care.
Value-Based Care is a game-changing advancements for patients and the providers who care for them. Value-based care is revolutionizing the healthcare industry and aligning incentives more and more each year. The concept of pay-for-performance, patient-centered care, and outcome measures have all been developed with the intention of providing more value to patients and healthcare providers alike. These new standards are also a response to the Affordable Care Act’s emphasis on cost containment and value in healthcare services. Therefore, it is no wonder that many hospitals and medical practices have adopted a value-based approach when considering how best to meet the needs of patients and the business needs that make care happen. However, navigating this new territory can be challenging without proper guidelines.
What is Value-Based Care?
Value-based care (VBC) is a system of payment designed to change the incentives for healthcare providers, so that they are rewarded for providing high-quality, cost-effective care. In VBC, providers are reimbursed based on the relative value of their services. The amount a provider is paid is based on the quality and outcomes of the services provided as well as their costs. Similar to the H and R Block tax model, providers are rewarded for going above and beyond what is expected of them. VBC providers are rewarded for providing high-quality and cost-effective care, whereas higher cost or decreased patient outcomes can result in financial penalties.
This is a significant change from the fee-for-service model that has long been the primary financial model for healthcare. In the fee-for-service model, healthcare providers are reimbursed based on the number, kind and cost of procedures and services provided to patients. More expensive procedures make providers more money, even when not medically necessary. And care that is shown to benefit the health of the patient but does not directly result in revenue for the practice is not financially viable and often gets overlooked (e.g. care-coordination, regular nurse follow-ups, ancillary services, nutrition, transportation, counseling, remote patient monitoring, and so many more).
The Basics of Value-Based Care
Value-based care is centered around the idea that quality and cost should be the focus in providing healthcare services. As such, it is the responsibility of healthcare providers to optimize the care they provide in terms of both quality and cost. This can be achieved by looking at the overall cost of care, rather than just the cost of the single procedure. The shift from volume to value in healthcare has been occurring over the past two decades. There have been many policy changes and legislative initiatives aimed at reducing healthcare costs by focusing on quality. Key indicators of the shift from volume to value include: The Balanced Budget Act of 1997; The formation of the Medicare Payment Advisory Commission (MedPAC); The creation of accountable care organizations (ACOs); The Affordable Care Act (ACA).
Key Strategies for Transforming to a Value-Based Care Environment
While the overarching goal of value-based care is to reduce healthcare costs while maintaining or improving quality, there are several strategies that providers can employ to make this transition.
Look at the big picture: Value-based care requires providers to look at the big picture of healthcare costs, which includes both the costs of the care being provided as well as the costs of delivering the care itself.
Focus on the patient: Value-based care should focus on patients and how they can expect to be treated. The focus should be on patient satisfaction scores and more personalized care.
Improve the care delivery process: By improving the care delivery process, providers can reduce errors and make it easier for patients to receive the care they need.
Who Is Responsible for Value-Based Care?
A number of different stakeholders are responsible for enacting value-based care at each step along the continuum of care. At the patient level, patients themselves play a critical role in the success of VBC. Patients should be providing honest feedback on the quality of care they receive and the outcomes they experience. Healthcare providers are responsible for coordinating the collection of data, assessing the value of the care they provide, and reporting on the outcomes of their services. Finally, payors are charged with using the information from providers to make risk-adjusted payments.
Identifying the Right Measures and Outcomes
As previously discussed, VBC providers are reimbursed based on the relative value of their services. The amount a provider is paid is based on the quality and outcomes of the services provided as well as their costs. In order to determine the relative value of a particular service, providers must first select the appropriate outcome measures.
In selecting outcome measures, providers should consider the following:
Is this outcome measure important to patients?
Is this outcome measure accurate?
Is this outcome measure feasible to collect?
Other Strategies to Consider: Staffing, Infrastructure and Technology
Beyond the strategy of selecting the right outcomes and measures for VBC, providers should also consider the following strategies when endeavoring to improve the delivery of quality and cost-effective care.
Staffing: There are a number of strategies that providers can employ to improve staffing outcomes, such as considering the optimal staffing mix, providing on-the-job training, and leveraging digital technologies to improve efficiency.
Infrastructure: In addition to factors such as the condition of the building, providers should also consider the functionality of their facilities, such as the accessibility of their services or the location of their facilities.
Technology: Providers should also consider the technologies they have in place, such as EHR systems, scheduling software, HCC coding education apps, and diagnostic equipment.
Conclusion
There are many benefits to adopting a value-based care approach. VBC providers are beginning to see improvement in outcomes, such as fewer avoidable hospitalizations, reduced readmission rates, increased patient satisfaction scores, improved quality scores, and lower mortality rates. Furthermore, providers who embrace VBC are actually seeing bottom-line financial benefits, as they are rewarded for providing high-quality, cost-effective care. However, adopting a value-based care approach is not without its challenges. In particular, providers must be willing to take a critical look at their current practices and begin to change where necessary. Along the way, providers should be transparent with their patients about the changes they are making, the things that are being actively improved, and the over-arching WHY behind their shift to Value-Based Care.
Value-Based Care is a natural movement toward the benefit of the patient. And as providers make the shift, patients will be encouraged both by the motive behind the transition as well as the improvement in their overall health and the reduction in the costs of their care. Truly, Value-Based Care has the potential to be a significant win-win for patients and providers. And in the end, isn’t that why you spent all those years pursuing your medical training? Value-Based Care is for patients, and for the providers who care for them.
HCC Coding And RAF are vital to modern healthcare, and we’ve recently received some incredible client data we’d very much like to share. And we all know the perils of sharing a win that deals with customer data, which is in turn patient data. And by “perils,” what we really mean is impossibility. Sometimes, the news is so good that it’s impossible not to share, yet so proprietary that it’s impossible to share. And so easily identifiable that it would be nearly impossible to anonymize.
And just the other day, we had just such a juicy morsel of intel shared internally, securely. And upon threat of death, we were told that we must not, in any way, share said information.
And let me tell you, it was a whopper. The Big Kahuna. The White Whale of case study fodder.
And as a member of our marketing team, let me just take a moment of personal privilege here to state emphatically THIS IS TOO GOOD NOT TO SHARE.
As The Man in Black once famously said, “But if there can be no arrangement, then we are at an impasse.”
And that’s where we are. We are at an HCC coding, recapture rate, value-based care, patient outcome boosting, revenue improving, data-backed customer case study impasse.
So, just to set the table for you, please know that this is the kind of client results data that, were you to see it, your immediate thought would be, “Golly, I want these results for my organization!” And then your next impulse would be to double-quick DOUBLE-click on the button labeled [Book A Demo] and hastily pick the first time slot available.
And your next move would be to share the source of your joy with your Chief Medical Officer, your Chief Technology Officer, your CFO, CEO, CXO. And from there, you would set ablaze the slack channels, email and maybe fire off a text or two.
And this is what you’d say:
“Team, these are the kind of results we need – and this is the tool we need to get us those results. This right here, DoctusTech has done it, and here’s the proprietary customer data from a recognized and well-respected name in the industry to back it up. And while they’ve tried to obscure the source, I’ve determined that it’s most likely [REDACTED]! Let’s jump on a demo right away, and get those same results for our org, ASAP!” (I paraphrase.)
And once the dust settled, and your demo was booked, and you shared just what prompted you to hastily beat down our digital door, I would be promptly hung by the ears. And the client who so graciously shared the impact our tools had on patient outcomes and their organizational bottom line would then set about hanging others by their respective ears and I would be out looking for gainful employment as a freelance beachcomber or plumber’s assistant. It would not be pretty.
So, to avoid all that unpleasantness, I’ve cut a little deeper into the specifics, redacting the customer-identifying data, obscured the actual data, and generalized the metrics to ensure that no client trust is being compromised. But at the same time, YOU, Healthcare Executive, are able to get the general gist of the compelling client data without risk to anyone’s ears or careers.
Here, without further ado, is the anonymized case study data from a highly respected name in the VBC space.
As you can see, you will need to use a little imagination to apply meaning to the data points, as it relates to your particular organization and the impact DoctusTech will have on your numbers. Whether it’s an increase in RAF accuracy, unique code capture, recapture rates, clinician fund of knowledge on HCC coding, RADV audit preparedness, accountability, patient care, improved diagnostic specificity, decreased clinician workload (invert graph) or improved team spirit, you can clearly see that the impact would be significant.
For further clarification and a demonstration, please do not hesitate to energetically and immediately click here to schedule that conversation with our team.
HCC coding education is a fast growing need for physicians. To meet the demands of today’s fast-paced and dynamic healthcare environment, many are now accelerating their transformation from a hospital-centered fee-for-service model to a more patient-centered model, and Value-Based Care is at the forefront of this change. The increased HCC coding knowledge requires clinicians to become more efficient with their time and resources as they are forced to master HCC coding in the gaps between patient care.
The focus on implementing coding education programs for clinicians is a hot topic. Unfortunately, many of the strategies being deployed actually add to the challenges clinicians face in the day-to-day. They do this by attempting to educate with outdated methods, forgetting some of the tried-and-true teaching techniques that worked so well in med school. Namely, clinical vignettes deployed using the Socratic method. In order to achieve the proficiency they need to code efficiently in real time, today’s clinicians need a solution that works well, without adding to their already stretched workload.
Whether you are just getting started with your organization’s coding education strategy or you want to take it to the next level, this blog post compares the four key HCC coding education strategies, highlighting their strengths and weaknesses.
1. Lecture by Zoom / Classroom
The classic classroom setting, training through seminars deployed in person or over Zoom. This method does allow you to reach a massive audience and deliver identical content to them.
If only doctors learned this way, it just might work! Unfortunately, most doctors come out of med school hard-wired to learn through clinical vignettes and the question and answer techniques, AKA the Socratic method. Why? Because while some people do not learn well in a lecture setting, med school teaches doctors how to retain massive amounts of information using this proven teaching strategy.
2. One-to-One Coaching
One-to-one coaching is the gold standard of HCC coding education. If there was one coach for every 5 clinicians, and if every clinician had time to be coached, this could work. And if every clinician learned the same way, it would work. But that is not the case! This strategy has its advantages. The sessions are intense and generally effective, as it results in an immediate correction to a clinician’s thought process. But this strategy will only work if clinicians have unlimited time and nearly unlimited coaches, which they do not. This method is super time-consuming, and do not forget, to organize this, you would need a massive staff to run the entire thing. Also, unlike Zoom classrooms, your reach is limited by geography.
3. Email Blast
Other than the fact that it does not work, it is great! Email is fast and easy, but also super easy to ignore. Whether you opt to share all the codes in a single email, or drip out Code of the Month in a series of emails, it still falls flat. Easiest to deploy, easiest to ignore, and hardest to retain.
4. DoctusTech App
We admit to a certain bias, but hear us out. Learning can be done on the doctor’s timeline, and there is no scheduling required. Track the progress and performance, and help them to learn more and focus on areas needing attention. The DoctusTech app is ideal for larger groups, helping clinicians learn without negatively impacting workload or patient care. JIT Learning enables clinicians to learn what they need when they need it. And without the limits of geography, the same HCC coding education can be deployed to all clinicians at once. No coaching staff to hire, train, deploy and manage. Accountability across the organization. Ease of use for clinicians with only a five minute lift per week.
To make learning interesting, the app uses gamification to keep things competitive and fun. Clinicians can see how their peers are doing, and that competitive drive kicks in, pushing learners to engage even more. And when new information, rules, and codes come out, the app serves content to rapidly update the whole org. This app is cost-effective, saves time, and provides real-time behavior change.
HCC Coding Education Matters
No matter where you are in your value based care journey, HCC coding education is a vital tool that your clinicians need right now.
The best way to learn HCC coding is in the DoctusTech app. The second best way is deploying an army of coaches. And if you are still using email or seminars to onboard new clinicians and teach HCC coding to your doctors, please schedule some time with our team. The DoctusTech app is less expensive, more effective and far simpler to deploy, use, manage and maintain than any of the other HCC coding education strategies.
Learn More about HCC Coding Education
Book a demo to see the best HCC coding education strategy in action.
The Office of Inspector General is cracking down on Medicare Advantage prior authorizations that were denied which would have been approved under fee-for-service Medicare rules. Excerpts from the OIG Medicare Advantage prior authorizations denial report follow, quoted in full, arranged for clarity, and followed by our comments.
The OIG audited “a stratified random sample of 250 denials of [Medicare Advantage] prior authorization requests and 250 payment denials issued by 15 of the largest MAOs during June 1−7, 2019.”
Inappropriately denied Medicare Advantage prior authorizations are the evil twin of up-coding. But rather than boosting profits by improperly increasing Risk Adjustment scores, this practice retains profits by denying appropriate care.
Medicare Coverage Rules
MAOs must follow Medicare coverage rules, which specify what items and services are covered and under what circumstances. Because MAOs must provide beneficiaries with all basic benefits covered under original Medicare, they may not impose limitations—such as waiting periods or exclusions from coverage due to pre-existing conditions—that are not present in original Medicare.
A central concern about the capitated payment model used in Medicare Advantage is the potential incentive for Medicare Advantage Organizations (MAOs) to deny beneficiary access to services and deny payments to providers in an attempt to increase profits.
Access to quality healthcare is a human right, and CMS wants to ensure that money is not getting in the way of that. Value-Based Care payment models are designed to align financial incentives with patient outcomes. On one side of the equation, CMS and the DOJ regularly audit (and prosecute) health plans and provider groups for up-coding or over-coding diagnoses that are not supported in the documentation – essentially, getting paid for providing needless care that does not benefit patients. In this report, OIG is looking at the other side of the coin: patient care that should have been provided, but was denied in appropriately.
Both are financial mechanisms to boost earnings or cut costs at the expense of patient care. And while we usually focus on the HCC coding and documentation side of the fence, denying care that should have been approved is potentially worse. Up-coding raise costs unnecessarily, but patients are still receiving care – although at times needlessly. By highlighting the problem of inappropriately denied care, OIG is actually uncovering a problem that is, in essence, refusing to provide appropriate and necessary care.
Key Takeaway
MAOs denied prior authorization and payment requests that met Medicare coverage rules by:
using MAO clinical criteria that are not contained in Medicare coverage rules;
requesting unnecessary documentation; and
making manual review errors and system errors.
By ratcheting up the clinical criteria beyond Medicare rules, MAOs that inappropriately deny coverage or payments are skimming the til at the expense of patient care.
By requiring unnecessary documentation beyond CMS guidelines, an MAO can appear to be taking documentation and accuracy very seriously, when in fact, they are actually just withholding care for profit.
What OIG Found
Our case file reviews determined that MAOs sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules. MAOs also denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules. Denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers. Although some of the denials that we reviewed were ultimately reversed by the MAOs, avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers, and MAOs. Examples of health care services involved in denials that met Medicare coverage rules included advanced imaging services (e.g., MRIs) and stays in post-acute facilities (e.g., inpatient rehabilitation facilities).
Prior authorization requests.
We found that among the prior authorization requests that MAOs denied, 13 percent met Medicare coverage rules—in other words, these services likely would have been approved for these beneficiaries under original Medicare (also known as Medicare fee-for-service). We identified two common causes of these denials. First, MAOs used clinical criteria that are not contained in Medicare coverage rules (e.g., requiring an x-ray before approving more advanced imaging), which led them to deny requests for services that our physician reviewers determined were medically necessary. Although our review determined that the requests in these cases did meet Medicare coverage rules, CMS guidance is not sufficiently detailed to determine whether MAOs may deny authorization based on internal MAO clinical criteria that go beyond Medicare coverage rules.
Second, MAOs indicated that some prior authorization requests did not have enough documentation to support approval, yet our reviewers found that the beneficiary medical records already in the case file were sufficient to support the medical necessity of the services.
Again, increasing clinical documentation requirements beyond CMS’ requirements is not cool.
Payment requests.
We found that among the payment requests that MAOs denied, 18 percent met Medicare coverage rules and MAO billing rules. Most of these payment denials in our sample were caused by human error during manual claims-processing reviews (e.g., overlooking a document) and system processing errors (e.g., the MAO’s system was not programmed or updated correctly). We also found that MAOs reversed some of the denied prior authorization and payment requests that met Medicare coverage rules and MAO billing rules. Often the reversals occurred when a beneficiary or provider appealed or disputed the denial, and in some cases MAOs identified their own errors.
What OIG Recommends
Our findings about the circumstances under which MAOs denied requests that met Medicare coverage rules and MAO billing rules provide an opportunity for improvement to ensure that Medicare Advantage beneficiaries have timely access to all necessary health care services, and that providers are paid appropriately.
Therefore, we recommend that CMS:
(1) issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews;
(2) update its audit protocols to address the issues identified in this report, such as MAO use of clinical criteria and/or examining particular service types; and
(3) direct MAOs to take steps to identify and address vulnerabilities that can lead to manual review errors and system errors. CMS concurred with all three recommendations.
In effect, the OIG is recommending adding a category to the already rigorous audits associated with MAOs. RADV audits may in the near future also address inappropriately denied Medicare Advantage prior authorizations.
So the takeaway here is to aim for the Goldilocks of clinical documentation integrity: neither too lax nor too strict, but just right, in line with CMS guidelines.
As always, we have an app for that. HCC education that helps your team achieve that perfect zen-like balance of accurate diagnoses, properly documented and ready for any audits. We deliver just-in-time learning on HCC codes related to conditions specific to the upcoming patient visits. And your clinicians earn 25 hours of CME per year, while operations achieves the Goldilocks of documentation: not too hot, and not too cold.
Revenue cycle management (RCM) is a hot topic this year. Monitoring, analyzing and improving the efficiency of your organization’s revenue processes is top of mind for leaders across many healthcare organizations. And you’ are probably still reading because you know that improving your organization’s revenue processes is essential to its success. But are you doing everything you can to implement a robust RCM strategy? Your competitors will not sit back and watch you take the lead. If you do not take action now, your competitors will leapfrog you with efficiency and better margins. . Read on for five ways that a strong RCM strategy will help improve your organization and drive financial success.
Build Strong Relationships with Partners
Revenue cycle management starts with strong relationships with your partners. This is especially true for organizations that rely on managed services or outsourcing partners to complete some or all of their revenue cycle activities. A strong partnership with your managed services providers will increase the likelihood that they will help you achieve your revenue goals.
Partners are crucial to your success, so you must work to build strong partnerships with them. How can you do that? First, decide how your organization will work with partners. Then, clearly communicate that decision to all partners with which your organization does business. Strong relationships with partners will help drive success in all other areas of revenue cycle management.
Improve Customer Experience
One of the best ways to improve your customer experience is through managed services. Providers of managed services can handle many customer-facing activities, such as claims processing, that your organization might struggle to handle on its own. Doing so will free up your staff to spend more time on strategic revenue-generating activities. Strong relationships with managed services providers are also essential for ensuring that clients receive a quality experience. If managed services providers are not communicating with your clients in a helpful, empathetic way, your organization’s reputation will suffer. You can avoid these problems by clearly communicating with managed services providers regarding your company’s communication strategies and expectations.
Improve Diagnostic Accuracy and Specificity
One of the fastest pathways to improving revenue is to repair broken methods of diagnosing chronic conditions in risk contracts. Diagnosing very specifically, HCC coding correctly and documenting very accurately can provide not only a direct boost to revenue, but improves outcomes in patient care. HCC coding is vital to successful risk contracts, so RCM requires your organization to improve the actual fund of knowledge within your individual team members. If your organization is educating clinicians in seminars or zoom calls, emails and PDFs, you are missing out on the opportunity to improve diagnostic specificity and accuracy. And while accurately diagnosing can improve patient care revenue, inaccurate HCC coding can have dire consequences on your org’s bottom line.
You might be hesitant to overhaul your HCC coding education, because it feels like a lot of work. However, it is far less of an organizational lift to improve training than it is to audit and fix errors along the way. And while some may claim that the new app-based HCC coding education is far less expensive than traditional training strategies, the real impact to revenue is cash flow positive. And that cost must be benchmarked against the inevitability of audits and repayments. Choose a partner you can trust to improve your team’s HCC coding, and see a direct impact to revenue, and simplification of the entire RCM process.
Monitor and Measure Key Performance Indicators
Management guru Peter Drucker once said, “Only what gets measured gets managed.“ No matter which areas of your revenue cycle you decide to focus on, you must monitor and measure your progress. This is critical for assessing the impact of your efforts and identifying areas where you might need to make changes. You can use metrics to measure customer experience, revenue cycle time, productivity, expenses and more. Choose the metrics that will help guide your RCM strategy the most. For example, customer retention and customer satisfaction metrics will be helpful for an organization that offers customer-facing products or services. RCM metrics that track the efficiency of your revenue cycle are also helpful for organizations that sell products and services. For example, tracking net revenue per customer and average revenue per customer over time can help you determine how well your revenue cycle is performing.
Automate Proven Processes
One of the easiest ways to improve your revenue cycle management strategy is to automate proven processes. If your organization is managing customer information, claims, billing or some other process manually, you are missing out on the opportunity to improve the process and save time and money. You might be hesitant to automate certain processes because you aren’t sure how they will work or if they will produce accurate results. If so, start small. Choose one process that you are confident will work as intended. Then, put the process into action. If it works as expected, implement it in other areas of your organization. If it does not work as planned, do not be afraid to scrap it and try something else.
Conclusion
Revenue cycle management is an essential strategy for all organizations. You cannot sit back and hope your revenue processes will improve on its own. It is the nature of RCM to get worse the moment you look away. You must take action to ensure that your organization is managing its revenue cycle as efficiently as possible. To succeed, you must work to build strong relationships with partners, improve your customer experience, improve diagnostic specificity and accuracy, monitor and measure key performance indicators, and automate proven processes. If you do, your revenue cycle management strategy will be strong and successful.
As the U.S healthcare system transitions towards value-based payment models, independent clinicians and physician groups continue to face HCC coding challenges that not only impact their bottom-line, but patient care as well. On top of all this, the pandemic has added a significant burden to the already stretched clinician workload.
Here are 4 key HCC coding challenges clinicians are facing now, and how they can overcome them.
Physician training for HCC coding – Physicians are already working tirelessly to provide excellent care to their patients. Asking them to learn HCC coding through brute-force via zoom calls, classroom seminars and email blasts is a bridge too far. On the other hand, the focus on value-based care has made it imperative for physicians to know and understand HCC coding so that they can accurately document patient records. So clinicians know they need to know, they just don’t have an effective and engaging mechanism for efficient and effective learning.
Revenue impact due to incorrect coding – Accurate HCC coding is necessary for accurate reimbursements and patient care, and inaccurate coding can directly impact the bottom line. That is why it is imperative that clinicians and staff be well trained in HCC coding. And the complexities don’t stop there. HCC codes not only impact RAF scores, they also interact directly with patient care, and a fair level of decision support is required , as HCC codes are not intuitive.
Poor HCC integration with EMR systems – When HCC coding does not integrate with the EMR, it creates a complex struggle for clinicians and physician groups. This not only leads to unintentional errors, but makes workflows more difficult and adds to the burden of an already heavy workload. It is critical to put a system in place that teaches clinicians to accurately document HCC codes on every patient, and integrates within the EMR.
Lack of trained HCC coding professionals – Staffing shortfalls not only plague small practices, but larger physician groups are short-staffed as well. A lack of well-trained staff may be related to revenue or rising salaries, which sometimes small practices are unable to sustain. And when larger hospitals acquire smaller practices, a shortage of trained staff is often just one side-effect. Training clinicians and non-clinical staff on HCC coding is vital.
Transitioning to a value-based care model will never be seamless until these challenges are solved. How? With our unique suite of HCC education and EMR integration tools, enabling physicians to learn HCC coding and integrate an AI-powered HCC coding system into their existing EMR platforms to drive efficiency and accuracy.
To learn how our HCC coding app lets physicians train for HCC coding click here.
To understand how our EMR integrated platform works, click here.
In a move that surprised very few in healthcare—and fewer on Capitol Hill—SCOTUS refused to hear UnitedHealth’s case against the 2014 Medicare Advantage Overpayment Rule. In the case of UNITEDHEALTHCARE CO., ET AL. V. BECERRA, SEC. OF H&HS, ET AL. the lower court’s ruling stands.
Back in 2018, a Fierce Healthcare headline announced, “Federal court nixes CMS overpayment rule, handing a big win to Medicare Advantage insurers.”
“U.S. District Judge Rosemary Collyer in D.C. sided with UnitedHealth, which argued the rule that requires MA plans to return overpayments based on an analysis of its members’ health status was ‘wholly inconsistent’ with Medicare fee-for-service requirements.”
And earlier in that same year, Fierce reported that, “DOJ abandons much of its Medicare Advantage fraud suit against UnitedHealth.”
For a brief moment, it looked like Medicare Advantage insurers might not be legally required to “return overpayments based on incorrect diagnoses to CMS within 60 days of identifying them.” Ethical questions aside, it looked like they just might get away with submitting invalid diagnoses, getting paid, and keeping the money.
Unfortunately for MA plans everywhere, that big win was predictably followed by an even bigger appeal. And this time, documentation, accuracy, specificity and accountability won big.
From the UnitedHealthcare Ins. Co. v. Becerra, United States Court of Appeals, District of Columbia Circuit, Aug 13, 2021:
The Overpayment Rule is part of the government’s ongoing effort to trim unnecessary costs from the Medicare Advantage program. Neither Congress nor CMS has ever treated an unsupported diagnosis for a beneficiary as valid grounds for payment to a Medicare Advantage insurer. Consistent with that approach, the Overpayment Rule requires that, if an insurer learns a diagnosis it submitted to CMS for payment lacks support in the beneficiary’s medical record, the insurer must refund that payment within sixty days. The Rule couldn’t be simpler. But understanding UnitedHealth’s challenge requires a bit of context.
The bottom line on The Medicare Advantage Overpayment Rule:
The Medicare Advantage Overpayment Rule has been weighed, measured and—for the time being—left standing, perhaps more firmly than before.
For greater context, the following is excerpted with attribution from a publication by Troutman Pepper. (Find the full text HERE)
The Affordable Care Act requires MA insurers to report and return any overpayments identified by the insurer to CMS within 60 days. Failure to do so can trigger liability under the False Claims Act. In 2014, CMS promulgated the Overpayment Rule to implement these statutory requirements and further specified that a “diagnosis that has been submitted [by a Medicare Advantage insurer] for payment but is found to be invalid because it does not have supporting medical record documentation would result in an overpayment.” Becerra, 2021 WL 3573766, at *10. For purposes of the rule, overpayments are “identified” when actually identified or when they should have been identified by the insurer “through the exercise of reasonable diligence.” “Reasonable diligence” is defined as “proactive compliance activities conducted in good faith by qualified individuals to monitor for the receipt of overpayments.” 42 C.F.R. § 422.326 at 29,921.
Documentation of a reported medical diagnosis is relevant here because of the way CMS pays MA insurers. Unlike traditional fee-for-service (FFS) Medicare payments, MA insurers receive pre-established monthly lump sum payments for each beneficiary they insure. The monthly payment amounts are intended to reflect the relative risk and cost of insuring any particular member. To that end, the Medicare statute requires a monthly payment adjustment to reflect “such risk factors as age, disability status, gender, institutional status, and … health status … , so as to ensure actuarial equivalence” between traditional Medicare and Medicare Advantage. MA insurers are then paid larger amounts for covering higher risk, costlier individuals. 42 U.S.C. § 1395w-23(a)(1)(C)(i).
CMS uses the Hierarchical Condition Category risk adjustment model to convert diagnosis data into expected costs for MA beneficiaries. The model uses data from individuals covered under the traditional Medicare program to determine medical costs associated with certain diagnosis and demographic information. CMS then uses this data to predict the cost of care for MA beneficiaries based on their demographics and diagnoses.
Since errors may occur in reporting diagnosis codes, CMS has implemented mechanisms, including the Overpayment Rule, to validate reported diagnoses. Another validation mechanism is the Risk Adjustment Data Validation audit through which CMS audits a sample of medical records for any unsupported diagnoses that may have resulted in an overpayment. CMS then extrapolates this sample’s error rate across all beneficiaries. At one point, CMS considered adding, but ultimately did not, an FFS adjuster to achieve actuarial equivalence in the RADV program. The FFS adjuster would be applied to any overpayment amounts to ensure that MA insurers were only liable for repayments that exceeded any payment errors under the traditional Medicare program. The FFS adjuster was at issue in the challenge to the Overpayment Rule before the D.C. Circuit.
Implications
With this opinion, the D.C. Circuit disfavored arguments advanced by Medicare Advantage insurers and the District Court, largely reinstating the Overpayment Rule and shoring up CMS’ authority to implement fraud prevention and cost containment measures in a variety of forms. Importantly though, this opinion did not disturb the significant victory Medicare Advantage insurers enjoyed at the District Court concerning the reasonable diligence requirement, which the court ruled could not be applied to lower the standard for False Claims Act Liability. Even so, Medicare Advantage insurers must remain diligent in their compliance procedures. As the Circuit Court made clear, CMS has several tools in its arsenal — including certification obligations, RADV audits, and the Overpayment Rule — to identify and recoup overpayments and to potentially impose substantial liability for erroneous coding submissions. Read the full article here.
RaDonda Vaught was just sentenced to three years of supervised probation. The former Vanderbilt University Medical Center nurse was found guilty of negligent homicide and gross neglect of an impaired adult in the death of a patient, because she administered vecuronium rather than Versed.
A tired, overworked nurse could not find the prescribed medication in an automatic drug dispensing cabinet, so she used an override and grabbed the wrong drug. Her patient died, and she was convicted of two felonies.
Burnout is a pervasive evil in any industry. But in healthcare, the stakes are measured in lives, and a career-ending error could also land a well-meaning provider in court, battling more than a malpractice suit.
The Rise and Fall and Rise of Physician Burnout
A study from 2019 demonstrated a decline in physician burnout [Source]. Good timing, as the burnout decline preceded an overall healthcare worker burnout event rivaling the black plague at a drag strip. Just one year after publication, COVID-19 ushered in the worst, longest, darkest season of overwork, stress and burnout the healthcare industry has seen in a century.
And with the industry marching predictably toward Value-Based Care, onboarding a new clinician comes with a massive learning curve. Requiring providers to add HCC coding to their already complex workflow is not only vital to improve the industry, it is increasingly mandated by CMS.
Add to it that none of this HCC coding was taught in medical school, and you have a perfect storm that even Clooney & Wahlberg would struggle to make sexy.
Why do they make it so hard?
The rising tide of burnout and the steady growth of VBC and HCC coding knowledge form enough of a riptide of impossibility for today’s practitioners. But the teaching methods being used to bludgeon new codes into the weary minds—and workflows—of new residents and established docs alike are downright cruel. Consider that HCC coding education is being deployed using some of the most arcane and ineffective teaching tools available today.
1 hour seminars are the lingua franca across nearly every provider group in a risk payment model. And if sitting in a classroom being talked at while pretending not to stare blankly at your phone was not bad enough, the two worst years in most providers’ careers were met by shifting those interminable seminars to a Zoom call, probably on your phone.
Consider the vital role that HCC coding plays in capturing critical diagnoses to be treated, documenting those diagnoses to keep them treated, and billing against Risk Adjustment scores to reimburse for essential healthcare services that keep patients out of the hospital.
And we are teaching these skills over a Zoom call? With providers more burnt-out than ever, and Zoom fatigue at a universal high – we are lecturing doctors on HCC coding over their phones? Is it a surprise that engagement is low? Is it a surprise that errors are high? Or that adoption of full risk models is sluggish at best?
And yes, one-to-one coaching is the gold standard, and those who provide this mission-critical service should be heralded in the streets and welcomed with ticker-tape parades. This is heroic work. But with global workforce shortages, there are definitely not enough coaches to tackle the task at hand. Not for all the clinicians in desperate need of a rapid increase in their fund of knowledge on VBC and HCC coding.
Is there really no other way?
Full disclosure: this is a blog post by a brand that has pioneered another way to teaching HCC coding to doctors. And it really works. But we are not here to sell you our solution. At the moment, we are only here to say as loudly and as clearly as we can that Ye Olde Ways™ are not working. And if there is a better way—which there is—we need to be running toward it like actual lives depended on it. And not just patient lives – doctor lives, nurse lives, NPs and PAs and coders and operators and the IT team, too. There is a lot at stake, and it’s time to search for answers.
Our Offer
If HCC Coding and Physician Burnout are at all on your radar, we’d love to share a solution to both. Better solutions are out there – and they outperform seminars and code-of-the-month email blasts for engagement and results. And they free up your coaches to focus on the 20% that need it the most.
Implementing Value-Based Care is essential for today’s physician. Value-based care is a system of payment and reimbursement that rewards healthcare providers for delivering high-quality, cost-effective care to patients. There are two ways to improve the value of care: improving the quality of care (fewer complications, less re-hospitalization, shorter length of stay, better patient experience); and reducing the cost of care (more efficient services, fewer administrative costs, reduction in waste and overuse of services).
What is value-based care?
Value-based reimbursement is a system that aims to reward healthcare providers for providing high-quality care at an affordable price. It is important to understand that value-based reimbursement is not the same as cost reduction. It is not about minimizing costs, but rather, it is about maximizing quality while keeping costs low.
Benefits of value-based care
Better patient outcomes and experience – Through improved value-based care, you will likely be able to reduce the number of complications, readmissions, and other negative outcomes that patients experience.
Reduced costs – An effective value-based care program will not only result in higher quality, but will also likely reduce your costs. You will be reimbursed for all of the services you provide, but only for the ones that meet your quality standards.
Increased revenue – Providing high-quality care can lead to greater patient satisfaction, word of mouth referrals from happy patients, and thus, more revenue.
Better reimbursement – A value-based care program will be focused on providing high-quality care, so your reimbursement should be higher as a result.
A sustainable business model – If you want to keep your business open and sustainable into the future, you must be able to adapt to the changing needs of your patients, payers, and providers. In order to do this, you must be open to new ideas and be willing to try new strategies. The best place to start is with value-based care.
How to implement value-based care effectively
Start with the end in mind – Before you can implement value-based care, you need to have a clear plan and vision for what your new value-based care program will look like.
Educate your staff – One of the most effective ways to implement value-based care is to educate your staff. HCC coding is not taught in medical school, so clinicians will need a fast and effective means of getting up to speed. Accurate and specific diagnosis coding for risk management will ensure better patient care and improved revenue. And when clinicians understand HCC coding, the process, the metrics, and how their work impacts these metrics, all of VBC just works better
Educate your patients – Another important aspect of implementing value-based care is to educate your patients about what it means and why it is important.
Measure the right things – The first step in implementing value-based care is to make sure that the metrics you are measuring are actually contributing to value.
Find ways to reduce costs – Although you want to increase revenue and improve reimbursement, you also want to minimize costs.
Find the right partners – Last but not least, you need to find the right partners to work with to implement your value-based care program. (We would love the opportunity to earn your partnership on educating clinicians on HCC coding, as well as integrating documentation accuracy and value-based diagnosis resources into your EMR. Get in touch to learn more.)
Measure outcomes and quality
Clinical outcomes – In order to determine if a patient is receiving high-quality care, you must be able to measure their clinical outcomes (metrics such as blood pressure, heart rate, blood sugar, or other lab values or diagnostic findings, e.g. pathology reports).
Patient experience – While clinical outcomes are important, they do not tell the whole story. Patients may be receiving high-quality care that is resulting in good outcomes, but they may also be receiving poor quality care that is resulting in bad outcomes.
Provider experience – In order to provide high-quality care, providers must receive high-quality training. In addition, they must have access to the right tools. If they do not, they will not be able to provide high-quality care.
Define your value-based care services
Identify your core services – Before you can define the value-based care services you will offer, you must first determine your core services.
Identify your add-on services – Once you have your core list of services, you can then identify add-on services that you offer patients but that are not absolutely required for them to receive care from you.
Assign value-based care units (VBUC) – Next, you must assign a value-based care unit cost (VBUC) to each service.
Create a menu of value-based care services – Once you have identified your core services and have assigned VBUCs to each one, you can then create a menu of value-based care services.
Summing up
Value-based care has the potential to transform healthcare in the United States. It is important to note, however, that value-based care is not a fad or trend that will quickly come and go. It is a system that has been around for decades and is continuously evolving as more is learned about what it takes to provide high-quality, cost-effective care to patients. If you want to survive and thrive in today’s healthcare environment, you must be willing and able to adapt to the changing needs of your patients, payers, and providers. The best place to start is with value-based care.
Looking for a quick HCC coding knowledge hack? Use this Quick Guide to identify HCC codes for risk adjustment. Diagnosis coding for value-based payment models is one of the key drivers for innovation in modern healthcare – aligning incentives with care in ways that were only talked about in decades past. However, without appropriate and deep HCC coding knowledge, properly documenting chronic conditions that risk adjust is simply not possible.
The need for HCC coding knowledge continues to rise, from ACOs to ACO REACH and to payors and groups in VBC contracts with varying degrees of risk. The CMS’s Alternative Payment Models (APM) increasingly require clinicians to have more than a basic understanding of HCC coding – mastery is becoming the industry standard. Mapping ICD-10 codes to HCCs (Hierarchical Condition Categories) is more than a simple conversion, knowing when and where to use which codes—and how to document accurately–is vital.
And while we advocate for tools that increase the fund of HCC coding knowledge across all relevant clinicians, we also know that your team almost certainly needs a quick-fix that can be deployed today.
You must be able to diagnose the severity of your patient population’s illness in order to accurately and effectively provide care. Obviously, there is an ROI discussion to be had around lost revenue for under-billing for sicker patients. But the bigger risk is under-caring for those patients, and failing to avoid preventable visits to the “expensive care” department.
Photo Credit: PIMS
And while there are those who believe that HCC coding should be in the bailiwick of coders, and clinicians should stick to treating the patients, most modern doctors understand the complex interweaving of the relationship between practicing medicine and following protocols. Diagnosing with a deep understanding of HCC coding and its impact on RAF scores and patient outcomes is an essential component of the modern doctor’s toolkit.
One key piece of that toolkit is a modern approach to HCC coding education, such as what you’ll find in the DoctusTech app. But for today’s lesson, we’re going to give you the shortcut – our HCC Quick Guide, free download.
“We have found that by using a simple workflow intervention and tool, physicians can ensure that their diagnosis coding is informed by HCCs and optimized for payers’ risk adjustment calculations.”
– AAFP
Obviously, we’re biased as to which workflow intervention tool physicians should be using. But before deploying a tool inside the EMR, physicians must be educated on HCC coding – and the old ways are simply not working. So if you need a quick fix, get our Quick Guide. And if it’s time to look into a real solution to cut onboarding times, and get physicians engaged in learning HCC coding and documentation, maybe it’s time to look into more than a quick fix.
And as you identify which chronic conditions have HCC codes that impact risk adjustment, documenting those correctly in the patient’s chart is an important next step. BUT, even if your team is capturing the appropriate codes, but not appropriately documenting, that diagnosis and the dollars earned against it are itching for a bad time. Not only is CMS bringing audits, the DOJ has increased scrutiny on VBC contracts and is incentivizing whistleblowers. This is no longer an area where you can get by on good intentions.
In VBC, not every chronic condition contributes to risk adjustment, so look for those conditions are weighted for risk adjustment – these will be the ones that require more costly care. Don’t rely on the EHR to do this for you, HCC coding knowledge is critical.
Our HCC Quick Guide can help you as your team dips toes in the water, but again, today’s clinicians badly need a deep and growing fund of knowledge on which diagnoses map to HCC codes, which contribute to risk adjustment, and how to document them.
Download the HCC Quick Guide now – print and post it, carry it, laminate it! This will be a vital tool as you lean into risk adjustment
Practicing in value-based payment models requires clinicians to diagnose and document all appropriate chronic conditions that contribute to Risk Adjustment Factor. Each condition must be documented and readdressed annually. This is a critical piece of the annual wellness visit, and any further appointments.
You cannot treat what you don’t diagnose. And you cannot bill against poorly documented diagnoses that have not been properly HCC coded. And you don’t get paid to treat conditions that do not contribute to Risk. So when you put that all together, HCC coding education should be a central component of your team’s toolkit.
It has long been thought that the machinery of the US healthcare system is so big, so complex and so established that steering the ship is nearly impossible. However, if we’ve learned anything from the COVID-19 pandemic, we can be nimble when we have to be. Lives were on the line, the nation itself was at stake, and The Industry dodged and weaved as nimbly as an NFL receiver. Truly, the entire industry adapted in ways that would have been called impossible a year earlier. Legislative and commercial interests flexed to co-author solutions that feel second nature today – so we know it can be done.
Enter Value-Based Care.
The market shift toward VBC has been slow, but for such an unwieldy thing to shift at all, it has been meaningful in its steadiness. The market is truly moving toward value. We recently blogged on the annual dollars paid in each model, from FFS to full risk, and the trend is a steady annual march. (Read that full blog here: The Rise of Risk: Value-Based Care Payments Increasing Year Over Year
The challenges and opportunities inherent in any change are perhaps more significant, as literally millions of lives hang in the balance. If the nation shifts toward VBC, the sick and aging have a much better chance of receiving better care. One study found that full-risk payment models correlated to a statistically significant decrease in avoidable hospitalizations. (Read the full report here: VBC: Full Risk Shows Lower Preventable Hospitalizations of MA Beneficiaries, Study)
Rather than the high volume-based rewards inherent in the fee-for-service model, value puts the revenue on the other side of patient health, rewarding better results in quality, outcomes, and costs.
But is this good? The CMS has made it clear that their goals for 2030 are a massive shift toward VBC, even though many of the benefits of the model are still largely theoretical. And documented benefits of organizations currently operating in VBC contracts—with either shared savings or varying degrees of risk—have even been deemed untrue, or correlated through dubious means like selection bias. And to be sure, some programs have favored less sick patients to avoid the risk of costly visits to the ED.
But overall, the benefits appear to be demonstrably there – and the industry is shifting. Glacially slow, sure. But shifting all the same.
And while some parts of the industry shifts, there are also vast swaths of healthcare that are so deeply entrenched in fee-for-service that they may never move. And maybe that’s not such a bad thing. After all, if there was no darkness, how would we know to be grateful for the daylight?
And so the industry gradually shifts toward value. Investors in the for-profit side of the business of health are taking notice of the ROI in well-run VBC programs. And conscientious investors are becoming more committed to the humanitarian side of wealth, urging boards to take a risk on risk in the interest of improved patient outcomes. And even the most pecuniary of fiduciaries are inclining toward value as the revenue cost-justifies the risk when things are done right a risk adjustment.
Photo Credit: Gallup.com
And yet, there are organizations that simply refuse to budge – and maybe never will shift to Value. And the reluctance to shift is almost reasonable. VBC incurs significant startup costs, and FFS pays pretty well. Why rock the boat? In a nearly even split between risk and FFS (40% / 40%), there is not yet enough market pressure to force the change.
But will that day come? Will the US consumer eventually learn about value-based care, and start to demand that providers and payors align their financial gains with patient outcomes?
Will legislation force or speed the shift?
Or will there always be fee-for-service as an unavoidable piece of the US healthcare system? And is that such a bad thing?
As we help organizations streamline their shifts into profitable VBC programs through our HCC coding education for doctors and our EMR integrated platform, in many ways, we are also watching from the sidelines.
And while some still say the jury is out, we’ve seen enough from the inside of some of the best operators in VBC to know that the case is closed. Sure, there is plenty of room for improvement. New legislation and increased scrutiny continue to make the compliance piece daunting to the uninitiated. But whether you’re operating the old FFS model, shifting toward VBC, or in it to win it, it’s more clear now than ever that Value-Base Care is the future, and it’s time to make the shift.
Got questions? Curious about the tools and resources required to raise RAF accuracy, boost diagnostic specificity, and lockdown documentation? Need your doctors to learn HCC coding yesterday? We get it. Value-Based Care is important, but it can also be incredibly complex and difficult.
The US healthcare market is leaning in the direction of Full Risk Value-Based Care. While the system is often characterized as a monolith; a massive, unwieldy machine (and as immovable objects go, it is a big one), that big machine is trending steadily toward full risk value-based care.
The CMS recently reported that total spending reached “$4.1 trillion or $12,530 per person [in 2020]. As a share of the nation’s Gross Domestic Product, health spending accounted for 19.7 percent…” That’s one out of five American dollars. And somehow, with all that money on the table, we still struggle to improve outcomes. (Source: CMS)
According to OECD.org, of the 38 member nations, The US spends more per-capita on healthcare than any other member nation. Also, our already lower-than-average life-expectancy took a higher-than-average hit from the pandemic. “The United States recorded the largest drop in life expectancy of any OECD country during the pandemic, falling from 78.9 in 2019 to 77.3 in 2020 – a decline of 1.6 years, compared to 0.6 years on average.” (Source: OECD)
With the US staring down these and myriad other daunting data points, this is an ideal time to chart a path forward, up, and out of the quagmire of fee-for-service stagnation. Thankfully, change is coming. As we recently posted in our blog, the total dollars of US healthcare spending are gradually shifting away from FFS, through Quality, and into risk models.
CMS Innovation Center has stated that its Goals for 2030 are that all Medicare and the vast majority of Medicaid beneficiaries will be in a care relationship with accountability for quality and total cost of care by 2030. They aren’t specifically stating the “full risk model” as their 2030 goal, but that is the trend and a worthy goal.
Photo Credit: careyhealthsciences.com
And on the topic of trends, doctors increasingly favor full-risk payment models. While educating clinicians—without the right tools—can be a daunting task, more and more clinicians are moving their small practices into full risk value-based care contracts. And while engagement is tricky without the right resources, doctors are consistently in agreement that the incentive alignment inherent within a full risk model is moving the business of medicine in a direction that validates the same noble reasons that compelled them into medical school: patient outcomes. And so long as doctors are supported with access to engaging and impactful HCC coding education, the transition to full risk will continue.
Why is Full Risk Value-Based Care growing, year over year?
As mentioned above, doctors practice medicine for one very simple reason: they want to help people. And while the past century has focused heavily on healing sick people, full risk value-based care models are empowering doctors to achieve an even nobler goal: to keep people healthy. And while pulling a sick patient back from the brink certainly has its thrills, real job satisfaction is found in keeping patients living stable, healthy lives – far away from the avoidable acute events that would have sent them to the ED.
Why do doctors care about Full Risk in Value-Based Care?
When the financial incentives align to incentivize better outcomes, or put another way, healthier patients, one product of that machine is a steady stream of happy doctors. The business goals agree with the doctors’ goals. And with the advent of better clinician HCC coding education tools, engagement is on the rise. And engaging with the tools to improve specificity and accuracy in diagnoses puts clinicians at the forefront of change. The more they engage, the more they learn; the more they learn, the better they diagnose; the better they diagnose, the more they can impact patient health before an avoidable acute health event occurs. Simply put, improving clinician engagement on HCC coding directly impacts every bottom line. ROI improves, ability to deploy more preventative measures improves, patient health improves and physician satisfaction inevitably rises.
What is slowing the transition to Full Risk in Value-Based Care?
Inevitably, there are blockers. As they say, no good deed goes unpunished. And it’s incredibly hard to move a massive machine – especially one that comprises one fifth of the nation’s gross domestic product. And frankly, much of the for-profit side of healthcare is resistant to a move away from fee-for-service. That model has grown the revenue streams of many massive corporations, whose shareholders are opposed to not-making-money. And whose leadership has a fiduciary responsibility to those shareholders to keep making money. And while Full Risk in Value-Based Care does show strong ROI, that revenue comes with strings—and risk—attached.
“There is activity in value-based care, but what we see as the biggest challenge is provider engagement… Providers need to understand how to be successful in value-based arrangements.”
— Dr. Andrei Gonzales, assistant vice president of value-based payments for Change Healthcare
The Department of Justice released an analysis of all False Claims Act settlements and judgments in the fiscal year 2021, and healthcare was the source of 5 out of 6 BILLION dollars in settlements and judgments. (Read more on our blog HERE and HERE) Medical fraud took the top line, but Medicare Advantage abuses like upcoding and over-coding—diagnosing conditions that were not in the chart—came in close behind. And these cash-grabs are only the ones that were caught – but they represent enough of a red flag that CMS, the DOJ, and the OSI are all looking very hard at recent changes in payment models. And a RADV audit is no longer the bogeyman exclusively haunting payors. In an effort to restore public trust and recoup misspent healthcare dollars, the Department of Justice and a host of other agency audits are increasing every year. And with whistleblowers rewarded up to 30% of the significant financial judgments, every employee stands to become a robber-baron just for speaking up. In effect, taking a massive cut of the ill-gotten gains.
Dr. Andrei Gonzales, assistant vice president of value-based payments for Change Healthcare said, “There is activity in value-based care, but what we see as the biggest challenge is provider engagement… Providers need to understand how to be successful in value-based arrangements.” (Source: ModernHealthcare)
Educating doctors is not an easy thing. Even Hippocrates himself required future doctors to vow to teach his children how to practice medicine if they cared to learn. Because with the ever-evolving fund of knowledge required just to stay in the stethoscope, the challenge is steep. And for modern providers, the ask is bigger than ever. But it does not have to be like Sysiphus, pushing his rock uphill every day, only to watch it roll back down again. Thankfully, with modern HCC education platforms like the DoctusTech app and integrated tools to drive engagement, today’s doctors have the potential to learn HCC coding faster and more deeply than ever before.
And the faster physicians can learn HCC coding, the faster we will see the industry shift toward to Full Risk in Value-Based Care. And while it may not be a panacea for all that ails the US healthcare system, the transition toward Full Risk in Value-Based Care is the single best way to align incentives, ease the clinician workload, improve outcomes and decrease costs.
Want to try teaching HCC coding to your doctors in a way that really works? No more zoom calls, no more email blasts – a truly engaging platform with proven results. Demo the DoctusTech app today – your doctors will thank you. The ROI from your risk contracts will thank you. Your patients will thank you. And you will help the US take a critical step toward Full Risk in Value-Based Care that actually works.
As we look forward to the release of ACPLAN’s 2022 Alternative Payment Method report, let’s review data from their previous six annual reports. One clear takeaway is that Value-Based Care payments increasing year over year is a trend that shows no signs of stopping. Trend lines point to the inevitable rise of Full Risk, but slowly – as most of the year-over-year movement is coming from transitions from FFS linked to quality to full VBC models.
Overview
The APM Framework is the LAN’s landmark achievement, establishing a common vocabulary and pathway for measuring successful payment models. Originally published in 2016 and refreshed in 2017, the Framework classifies Alternative Payment Models (APMs) in four categories and eight subcategories, specifying decision rules to standardize classification efforts. It lays out core principles for designing APMs, which have influenced payers and purchasers, and forms the basis of the annual APM Measurement Effort. Private payers like Anthem use the Framework to set value-based payment goals, and at least 12 state Medicaid agencies use it to set value-based purchasing requirements in contracts with managed care organizations.
From the HCPLAN, Health Care Payment Learning & Action Network
HCPLAN Annual Reports show Increasing Value-Based Care Payments
Within the constructs of this framework, the LAN publishes a yearly report of dollars spent across the four categories, from Category 1(traditional Fee-For-Service or other legacy payments not linked to quality), Quality Category 2 (pay-for-performance or care coordination fees), and Categories 3 & 4 (VBC arrangements with shared savings, shared risk, bundled payment, population-based payments, integrated finance and delivery system payments).
Industry trending toward VBC, Risk, Value-Based Care Payments Increasing
By plugging in data from their annual reports, we can see that the market-share of the various payment models has been shifting toward categories 3 & 4, VBC arrangements with shared savings, shared risk, bundled payment, population-based payments, integrated finance, and delivery system payments.
The trends are clear and compelling: dollars spent in category 3 & 4 payment models are steadily rising, category 2 (pay-for-performance or care coordination) is declining, and Fee-For-Service is gradually shifting downward.
Since releasing their first report in 2016, HCPLAN has been tracking not just the dollars spent, but the trends over time. The below graphic shows one view of the data, as dollars spent increase across all payment models, but does not show the changing position of the various models.
CMS Innovation Center Goals Dictate Value-Based Care Payments Increasing
The CMS Innovation Center has stated that the goals of their strategic direction are that:
All Medicare fee-for-service beneficiaries will be in a care relationship with accountability for quality and total cost of care by 2030.
The vast majority of Medicaid beneficiaries will be in a care relationship with accountability for quality and total cost of care by 2030.
While the 2030 goal appears ambitious, the trend-lines are trending in that direction. Not only is Value-Based Care increasing as a total percentage of all payments, but specifically categories 3 & 4 are increasing against category 2. The movement is both away from Fee-For-Service and moving toward full risk models.
HCPLAN Annual Reports Demonstrate Increasing Value-Based Care Payments
Below, we have linked all the HCPLAN data from previous year’s studies, with links to their interactive reports. The data is clearly pointing to Value-Based Care payments increasing, year-over-year.
The overall change from 2019 to 2020 was very small, with Categories 3 & 4 gaining most ground from Category 2, and Category 1 (FFS) moving very little. It will be interesting to see how 2021 measures up.
Will Category 1 remain stalled at 39.3%, or will things continue shifting away from FFS? Will Categories 3 & 4 continue to take from Category 2, or will FFS give up a few of its dollars to VBC? We are grateful for the work of the LAN, and eager to see the next report. Optimistic, even!
Notes and insights from a study published by AJMC on how to change physician behavior. “The authors evaluated methods for implementing clinical research and guidelines, in order to change physician practice patterns, in surgical and general practice. They evaluated the effectiveness of different implementation methods.”
And as we have demonstrated through successful behavior change in physicians using our HCC coding education app, the most common solutions aren’t the most effective when it comes to ongoing positive change in physician behavior. Want to learn how to change physician behavior? Let’s dig a little deeper into a review of reviews, revealing some hard truths.
We’ve been saying for years, lectures do not work. Emails do not work. If you want to know how to change physician behavior on HCC coding, don’t take our word for it. The American Journal of Managed Care released a systematic review evaluating fourteen medical reviews in an effort to understand which interventions are most effective in changing physician behavior for the better and improving patient outcomes.
It is evident from their publication that the methods of intervention most commonly deployed in teaching doctors HCC coding are rarely able to create lasting change in physician behavior.
Passive PEMs are not how to change physician behavior.
… reviews showed that formal didactic conferences and passive forms of CME, such as brochures or printed educational materials (PEMs), are the least effective methods for change and, at best, create small changes within practice. Other forms of passive dissemination, such as mailing PEMs to clinicians, were also deemed ineffective in changing physician behavior when used alone.
However, printed educational materials may be effective for raising awareness about specific behavior change. It is important to recognize that these passive approaches represent the most common approaches adopted by various healthcare organizations.
So to reiterate, the most common approach is to distribute printed materials, emails, PDFs, flyers, email blasts and the like. And this is shown to be the least effective approach.
The goal of continuing medical education (CME) for many medical professionals is to do more than raise awareness. Rather, the aim of CME is to see ongoing growth in physician performance. What methods then are most effective for creating the desired change?
Active and multifaceted methods are how to change physician behavior.
Various implementation methods are utilized to try and change physician behavior, and implementing the most effective ones is crucial to success. Our findings provide a comparison of relative effectiveness of various interventions, indicating that active forms of CME and multifaceted interventions are the most effective. In general, active approaches to changing physician performance have been shown to improve practice to a greater extent than traditional passive methods.
Active approaches … led to greater effects than traditional passive approaches. According to the findings of 3 reviews, 71% of studies included in these reviews showed positive change in physician behavior when exposed to active education methods and multifaceted interventions.
Active education methods and multifaceted interventions are the most effective when it comes to growth in physician behavior. The DoctusTech App is designed to provide active education and multifaceted interventions. In short, our app helps facilitate your desired growth as a physician. In fact, our app excels at providing the most effective methods of intervention.
…interactive education methods were identified in 3 reviews as highly effective single intervention methods for changing physician practice patterns. Interactive educational methods or active forms of CME are non didactic or lecture-based learning, focus on facilitating physician discussion, and link education experience to the physician’s clinical cases. Reminders (concurrent and automatic) were also recommended due to consistent positive results.
Deep learning is about more than gathering knowledge.
Deep learning is about more than gathering knowledge. The best way to learn is to practice and apply information. Our app allows for interactive and engaged learning by offering challenging questions in a clinical vignette to both teach and reveal gaps in knowledge while offering explanations that deepen understanding.
…learning linked to clinical practice and self-directed multifaceted active educational methods both resulted in improved physician performance.
Our study indicated that practices should focus on implementation of active methods to change physician behavior and limit use of passive dissemination of educational material or formal didactic conferences.
The DocusTech App is also multifaceted in its approach to improving physician performance! Along with engaging questions, our app incentivizes and gamifies the learning process by comparing the results within your organization in order to determine where you organization lands externally with all users. The challenging questions and incentivizing nature of our app is designed to promote deep engagement through ongoing discussion and learning among physicians.
…multifaceted interventions were most effective in changing physician practice patterns. Multifaceted interventions included a combination of active interventions: audit and feedback, reminders, local consensus or marketing, academic outreach, and interactive education.
The DoctusTech app knows that Active and Multifaceted methods are how to change physician behavior.
The DoctusTech App utilizes the same methods that have proven to help improve physician behavior. And just to reiterate, this is not a zoom call, a classroom style lecture, an email blast, or printed flyers. There are proven to be far less impactful or effective. Our app utilizes the most advanced intervention methods with the aim of replacing boring and ineffective lecture-style learning with engaging, challenging, and on-demand learning through questions that test your knowledge while filling-in knowledge gaps.
…multifaceted interventions and active forms of CME were rated the most effective implementation methods to change physician behavior for a desired outcome.
Are you struggling with how to change physician behavior?
See how the DoctusTech app is changing physician behavior right now! Using multifaceted and deeply engaging interventions, educating physicians on HCC coding has never been more effective and efficient.
Schedule a conversation with Dr. Kazi today, and start to see change physician knowledge, behavior and accuracy in HCC coding today!.
Medicare Advantage Compliance Audits: The Department of Health and Human Services Office of Inspector General regularly audits Medicare Advantage contracts and reports out specific diagnosis codes deemed improper. They also report the estimated overpayments associated with the specific diagnosis codes, and recommend repayments. Below, you’ll find all of the specific “High Risk HCC codes” targeted in these recent HHS OIC Medicare Advantage compliance audits.
High Risk HCC codes targeted in 6 recent HHS OIG Medicare Advantage compliance audits:
And the organizations associated with misuse
Acute stroke: An enrollee received an acute stroke diagnosis (which maps to the HCC entitled Ischemic or Unspecified Stroke) on one or two physician claims during the service year but did not have that diagnosis on a corresponding inpatient hospital claim. A diagnosis of history of stroke (which indicates that the provider is evaluating or treating residual conditions left behind by a prior stroke and which does not map to an HCC) typically should have been used. Anthem, Coventry, Healthfirst, Tufts, UPMC
Major depressive disorder: An enrollee received a major depressive disorder diagnosis (which maps to the HCC entitled Major Depressive, Bipolar, and Paranoid Disorders) on one or two claims during the service year, rather than on several claims, which would have reflected long-term treatment. It is possible that a diagnosis of a less severe form of depression (which does not map to an HCC) should have been used. Anthem, Coventry, Healthfirst, Tufts, UPMC
Acute heart attack: An enrollee received one diagnosis that mapped to either the HCC for Acute Myocardial Infarction or to the HCC for Unstable Angina and Other Acute Ischemic Heart Disease (Acute Heart Attack HCCs) on only one physician claim but did not have that diagnosis on a corresponding inpatient hospital claim (either within 60 days before or 60 days after the physician’s claim). A diagnosis for a less severe manifestation of a disease in the related-disease group typically should have been used. Anthem, Coventry, Tufts, UPMC
Acute stroke and acute heart attack combination: An enrollee met the conditions of both the acute stroke and acute heart attack high-risk groups in the same year. Anthem, Coventry, Healthfirst, Tufts, UPMC
Embolism: An enrollee received one diagnosis that mapped to either the HCC for Vascular Disease or to the HCC for Vascular Disease With Complications (Embolism HCCs) but did not have an anticoagulant medication dispensed on his or her behalf. An anti-coagulant medication is typically used to treat an embolism. A diagnosis of history of embolism (an indication that the provider is evaluating a prior acute embolism diagnosis, which does not map to an HCC) typically should have been used. Anthem, Coventry, Healthfirst, Tufts, UPMC
Incorrectly Submitted Diagnosis Codes for Breast Cancer: UPMC Incorrectly Submitted Diagnosis Codes for Colon Cancer : , UPMC Incorrectly Submitted Diagnosis Codes for Lung Cancer: , UPMC
Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services (CMS) makes monthly payments to MA organizations according to a system of risk adjustment that depends on the health status of each enrollee. Accordingly, MA organizations are paid more for providing benefits to enrollees with diagnoses associated with more intensive use of health care resources than to healthier enrollees, who would be expected to require fewer health care resources.
To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS. Some diagnoses are at higher risk for being miscoded, which may result in overpayments from CMS.
In the past few months, a large number of these audits have been released. Here are the summaries of just a few.
HHS OIC Medicare Advantage compliance audit #1
Humana, Inc. – $197.7 Million
How OIG Did This Audit
For this audit, we reviewed one of the contracts that Humana, Inc., has with CMS with respect to the diagnosis codes that Humana submitted to CMS. Our objective was to determine whether Humana submitted diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements.
We selected a sample of 200 enrollees with at least 1 diagnosis code that mapped to an HCC for 2015. Humana provided medical records as support for 1,525 HCCs associated with the 200 enrollees. We used an independent medical review contractor to determine whether the diagnosis codes complied with Federal requirements.
Humana Did Not Submit Some Diagnosis Codes in Accordance With Federal Requirements
Some of the Diagnosis Codes That Humana Submitted to CMS
Were Not Supported in the Medical Records
Diagnosis Codes That Humana Should Have Submitted but Did Not
Submit to CMS
What OIG Found
Humana did not submit some diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements. First, although most of the diagnosis codes that Humana submitted were supported in the medical records and therefore validated 1,322 of the 1,525 sampled enrollees’ HCCs, the remaining 203 HCCs were not validated and resulted in overpayments. These 203 unvalidated HCCs included 20 HCCs for which we identified 22 other, replacement HCCs for more and less severe manifestations of the diseases. Second, there were an additional 15 HCCs for which the medical records supported diagnosis codes that Humana should have submitted to CMS but did not.
Thus, the risk scores for the 200 sampled enrollees should not have been based on the 1,525 HCCs. Rather, the risk scores should have been based on 1,359 HCCs (1,322 validated HCCs + 22 other HCCs + 15 additional HCCs). As a result, we estimated that Humana received at least $197.7 million in net overpayments for 2015. These errors occurred because Humana’s policies and procedures to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective.
What OIG Recommends and Humana’s Comments
We recommend that Humana refund to the Federal Government the $197.7 million of net overpayments and enhance its policies and procedures to prevent, detect, and correct noncompliance with Federal requirements for diagnosis codes that are used to calculate risk-adjusted payments.
Humana disagreed with our findings and with both of our recommendations. Humana provided additional medical record documentation which, Humana said, substantiated specific HCCs. Humana also questioned our audit and statistical sampling methodologies and said that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program. After reviewing Humana’s comments and the additional information that it provided, we revised the number of unvalidated HCCs for this final report. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program. We revised the amount in our first recommendation from $263.1 million (in our draft report) to $197.7 million but made no change to our second recommendation.
For this audit, we reviewed one MA organization, UPMC Health Plan, Inc. (UPMC), and focused on 10 groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that UPMC submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.
We sampled 280 unique enrollee-years with the high-risk diagnosis codes for which UPMC received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $975,223.
Most of the Selected High-Risk Diagnosis Codes That UPMC Submitted to CMS Did Not Comply With Federal Requirements
Incorrectly Submitted Diagnosis Codes for Acute Stroke
Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
Incorrectly Submitted Diagnosis Codes for Acute Stroke and Acute Heart Attack Combination
Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
Incorrectly Submitted Diagnosis Codes for Embolism
Incorrectly Submitted Diagnosis Codes for Vascular Claudication
Incorrectly Submitted Diagnosis Codes for Lung Cancer
Incorrectly Submitted Diagnosis Codes for Breast Cancer
Incorrectly Submitted Diagnosis Codes for Colon Cancer
Potentially Mis-keyed Diagnosis Codes
What OIG Found
With respect to the 10 high-risk groups covered by our audit, most of the selected diagnosis codes that UPMC submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 194 of the 280 enrollee-years, the diagnosis codes that UPMC submitted to CMS were not supported in the medical records and resulted in $681,099 of net overpayments for the 194 enrollee-years.
These errors occurred because the policies and procedures that UPMC had to ensure compliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. On the basis of our sample results, we estimated that UPMC received at least $6.4 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.
What OIG Recommends and UPMC Comments
We recommend that UPMC refund to the Federal Government the $6.4 million of estimated net overpayments; identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and continue its examination of existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS’s risk adjustment program) and take the necessary steps to enhance those procedures.
UPMC disagreed with our findings and recommendations. UPMC provided additional information which, according to UPMC, validated HCCs for 25 sampled enrollee-years. UPMC questioned both our audit methodology and the qualifications of our independent medical review contractor. UPMC also stated that we did not calculate overpayments according to CMS requirements and that it disagreed with our extrapolation methodology and our assessment of its compliance program. After reviewing UPMC’s comments and the additional information that it provided, we revised the number of enrollee-years in error for this final report. We followed a reasonable audit methodology, used a qualified medical review contractor, correctly applied applicable Federal requirements underlying the MA program, and properly assessed UPMC’s compliance program. We revised the amount in our first recommendation from $6.6 million (in our draft report) to $6.4 million but made no change to our other recommendations.
We sampled 240 unique enrollee-years with the high-risk diagnosis codes for which Healthfirst received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $787,928.
Most of the Selected High-Risk Diagnosis Codes That Healthfirst Submitted to CMS Did Not Comply With Federal Requirements
Incorrectly Submitted Diagnosis Codes for Acute Stroke
Incorrectly Submitted Diagnosis Codes for Acute Stroke and Acute Heart Attack Combination
Incorrectly Submitted Diagnosis Codes for Embolism
Incorrectly Submitted Diagnosis Codes for Vascular Claudication
Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
Potentially Mis-keyed Diagnosis Codes
What OIG Found
With respect to the seven high-risk groups covered by our audit, most of the selected diagnosis codes that Healthfirst submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 155 of the 240 enrollee-years, the diagnosis codes that Healthfirst submitted to CMS were not supported in the medical records and resulted in net overpayments of $516,509.
These errors occurred because the policies and procedures that Healthfirst had to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. On the basis of our sample results, we estimated that Healthfirst received at least $5.2 million in net overpayments for these high-risk diagnosis codes in 2015 and 2016.
What OIG Recommends and Healthfirst Comments
We made a series of recommendations to Healthfirst, including that it: refund to the Federal Government the $5.2 million of net overpayments; identify, for the diagnosis codes described in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and continue its examination of existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes that are at high risk for being miscoded comply with Federal requirements and take the necessary steps to enhance those procedures.
Healthfirst objected to all of our recommendations; however, it did not object to any of the errors we identified. Instead, Healthfirst requested we limit our recommended recovery to the overpayments identified in our sample-not the extrapolated value of those overpayments. Healthfirst stated that OIG lacked the authority to use extrapolation to recommend a repayment and disagreed with our extrapolation methodology. It also stated that our audit methodology did not account for a payment principle known as “actuarial equivalence” and disagreed that it should perform audits of high-risk diagnoses or enhance its compliance program. After reviewing Healthfirst’s comments, we maintain that our findings and recommendations are valid. No statutory authority limits our use of extrapolation to estimate a recovery and we correctly applied Federal requirements underlying the MA program.
For this audit, we reviewed one MA organization, Tufts Health Plan, Inc. (Tufts), and focused on seven groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Tufts submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.
We sampled 212 unique enrollee-years with the high-risk diagnosis codes for which Tufts received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $746,427.
Most of the Selected High-Risk Diagnosis Codes That Tufts Health Plan Submitted to CMS Did Not Comply With Federal Requirements
Incorrectly Submitted Diagnosis Codes for Acute Stroke
Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
Incorrectly Submitted Diagnosis Codes for Acute Stroke and Acute Heart Attack Combination
Incorrectly Submitted Diagnosis Codes for Embolism
Incorrectly Submitted Diagnosis Codes for Vascular Claudication
Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
Potentially Mis-keyed Diagnosis Codes
What OIG Found
Most of the selected diagnosis codes that Tufts submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 58 of the 212 sampled enrollee-years, the medical records validated the reviewed Hierarchical Condition Categories (HCCs). However, for the remaining 154 enrollee-years, the diagnosis codes were not supported in the medical records. These errors occurred because the policies and procedures that Tufts had to ensure compliance with CMS’s program requirements, as mandated by Federal regulations, could be improved. As a result, the HCCs for some of the high-risk diagnosis codes were not validated. On the basis of our sample results, we estimated that Tufts received at least $3.7 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.
What OIG Recommends
We recommend that Tufts: (1) refund to the Federal Government the $3.7 million of net overpayments; (2) identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and (3) continue to improve its existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS’s risk adjustment program) and take the necessary steps to enhance those procedures.
Tufts did not concur with our findings and recommendations. Tufts stated that we should not have included the errors associated with 5 enrollee-years in our calculation of total net overpayments because, according to Tufts, it had already submitted corrections to CMS. Tufts did not specifically comment on the errors associated with the other 154 enrollee-years. Tufts disagreed with our sampling and review methodologies, and stated that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program.
After consideration of Tufts’ comments, we maintain that our findings and recommendations are valid. However, we revised our findings for the 5 enrollee-years and considered the impact of the budget sequestration reduction; therefore, we reduced our first recommendation from $4,013,034 to $3,758,335 for our final report. We also revised the beginning of our third recommendation in recognition of Tuft’s past efforts to improve its compliance program.
Anthem Community Insurance Company, Inc. – $3.47 million
How OIG Did This Audit
For this audit, we reviewed one MA organization, Anthem Community Insurance Company, Inc. (Anthem), and focused on seven groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Anthem submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.
We sampled 203 unique enrollee-years with the high-risk diagnosis codes for which Anthem received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $599,842.
Most of the Selected High-Risk Diagnosis Codes That Anthem Submitted to CMS Did Not Comply With Federal Requirements
Incorrectly Submitted Diagnosis Codes for Acute Stroke
Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
Incorrectly Submitted Diagnosis Codes for Acute Stroke and
Acute Heart Attack Combination
Incorrectly Submitted Diagnosis Codes for Embolism
Incorrectly Submitted Diagnosis Codes for Vascular Claudication
Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
Potentially Mis-keyed Diagnosis Codes
What OIG Found
With respect to the seven high-risk groups covered by our audit, most of the selected diagnosis codes that Anthem submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 123 of the 203 enrollee-years, the diagnosis codes that Anthem submitted to CMS were not supported in the medical records and resulted in $354,016 of net overpayments for the 203 enrollee-years.
These errors occurred because the policies and procedures that Anthem had to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. On the basis of our sample results, we estimated that Anthem received at least $3.47 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.
What OIG Recommends and Anthem Comments
We recommend that Anthem refund to the Federal Government the $3.47 million of net overpayments; identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and enhance its compliance procedures to focus on diagnosis codes that are at high risk for being miscoded by (1) determining whether these diagnosis codes (when submitted to CMS for use in CMS’s risk adjustment program) comply with Federal requirements and (2) educating its providers about the proper use of these diagnosis codes.
Anthem did not concur with our findings and recommendations. Anthem disagreed with our findings for 2 specific enrollee-years and provided additional explanations. Anthem also did not agree with the methodologies that we used to review the selected diagnoses and to calculate the $3.47 million of net overpayments. Anthem also said that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program.
After reviewing Anthem’s comments and the information provided, we maintain that all of our findings and recommendations remain valid. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program.
For this audit, we reviewed one MA organization, Coventry Health Care of Missouri, Inc. (Coventry), and focused on six groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Coventry submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.
We judgmentally selected 275 unique enrollee-years with the high-risk diagnosis codes for which Coventry received higher payments for 2014 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $701,593.
Most of the Selected High-Risk Diagnosis Codes That Coventry Submitted to CMS Did Not Comply With Federal Requirements
Incorrectly Submitted Diagnosis Codes for Acute Stroke
Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
Incorrectly Submitted Diagnosis Codes for Embolism
Incorrectly Submitted Diagnosis Codes for Vascular Claudication
Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
Potentially Mis-keyed Diagnosis Codes
What OIG Found
Most of the selected diagnosis codes that Coventry submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 226 of the 275 enrollee-years, the diagnosis codes that Coventry submitted to CMS were not supported in the medical records.
These errors occurred because the policies and procedures that Coventry had to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. As a result, Coventry received $548,852 of net overpayments for 2014 through 2016.
What OIG Recommends and Coventry’s Comments
We recommend that Coventry refund to the Federal Government the $548,852 of net overpayments; identify, for the diagnoses included in this report, similar instances of noncompliance that occurred during our audit period that we did not review and outside of our audit period and refund any resulting overpayments to the Federal Government; and enhance its compliance procedures to focus on diagnosis codes that are at high risk for being miscoded by: (1) educating its providers about the proper use and documentation of these diagnoses and (2) determining whether these diagnosis codes (when submitted to CMS for use in CMS’s risk adjustment program) comply with Federal requirements.
Coventry agreed that most of the reviewed diagnosis codes were not supported by medical records and said that it had identified $542,541 to refund to the Federal Government. However, Coventry did not agree with the other findings associated with our first recommendation and submitted additional documentation for our consideration. Coventry did not agree with our other recommendations and said that our report contained a number of serious flaws that fundamentally undermined our audit methodology, findings, and recommendations. Coventry also stated that it had made enhancements to its compliance processes since our audit period, including provider education.
After reviewing Coventry’s comments and the additional documentation that it provided, we revised the number of enrollee-years in error. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program. We revised the recommendation to refund overpayments from $584,005 (in our draft report) to $548,852 and slightly revised some of the language in our third recommendation.
Excerpts, notes and quotes from the DOJ 2021 Fiscal Year Report
The DOJ DOJ Healthcare Audits Charged $5 Billion In 2021, according to a recent report. The Department of Justice released an analysis of all False Claims Act settlements and judgments in fiscal year 2021, revealing $5 Billion against healthcare, out of a $5.6B total. Healthcare represented 89% of all DOJ FCA judgments and settlements for the year.
The False Claims Act is the government’s primary civil tool to redress false claims involving other government operations and functions.
“The Justice Department obtained more than $5.6 billion in settlements and judgments from civil cases involving fraud and false claims against the government in the fiscal year ending Sept. 30, 2021”
— Acting Assistant Attorney General Brian M. Boynton of the DOJ’s Civil Division
In the False Claims Act history, this is the second largest annual total, and the largest since 2014. Settlement and judgments now total north of $70 billion since 1986, when Congress substantially strengthened the civil False Claims Act by boosting incentives up to 30% for whistleblowers. In 2021, whistleblowers filed 598 qui tam suits.
DOJ Healthcare Audits account for nearly 90% of all DOJ charges
Of the more than $5.6 billion in settlements and judgments reported by the Department of Justice this past fiscal year, over $5 billion relates to matters that involved the healthcare industry, including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories and physicians. The amounts included in the $5 billion reflect recoveries arising from only federal losses, and, in many of these cases, the department was instrumental in recovering additional amounts for state Medicaid programs.
“Ensuring that citizens’ tax dollars are protected from fraud and abuse is among the department’s top priorities… The False Claims Act is one of the most important tools available to the department both to deter and to hold accountable those who seek to misuse public funds.”
— Acting Assistant Attorney General Brian M. Boynton of the DOJ’s Civil Division
First Place: Health Care Fraud
Healthcare fraud was once again in the lead as the top source of the department’s False Claims Act settlements and judgments. The department’s efforts restore funds to federal programs such as Medicare, Medicaid and TRICARE and prevent billions in losses by acting as a deterrent. Often, also protecting patients from medically unnecessary or potentially harmful actions.
Second Place: Medicare Advantage
Prosecuting Plans AND Providers for Over-Coding, Up-Coding
In 2021, more than 26 million Medicare beneficiaries were enrolled in Medicare Advantage plans, and the Congressional Budget Office projected that CMS would pay more than $343 billion for those plans.
The department has pursued plans and healthcare providers that manipulated the risk adjustment process by submitting unsupported diagnosis codes to make their patients appear sicker than they actually were. This year, Sutter Health, a California-based health care services provider, paid $90 million to resolve allegations that it knowingly submitted unsupported diagnosis codes for certain patient encounters, resulting in inflated payments to be made to the Medicare Advantage Plans and Sutter Health. In addition, Kaiser Foundation Health Plan of Washington, formerly known as Group Health Cooperative (GHC), paid $6.3 million to resolve allegations that it submitted invalid diagnoses and received inflated payments as a result. In addition, the department intervened and filed complaints in separate lawsuits against Independent Health Corporation and members of the Kaiser Permanente consortium alleging that those Medicare Advantage organizations submitted or caused the submission of inaccurate information about the health status of beneficiaries enrolled in their plans to increase reimbursement from Medicare.
Specificity and accuracy are the keys to any successful Value-Based Care program. And clinical vignettes are a great way to learn.
Five years ago, the AAFP (American Academy of Family Physicians) published a crash course to educate family physicians on HCC coding. To this day, the clinical vignettes from this family physician HCC coding education course are still a great example of how and why family physicians need to diagnose specifically and code accurately in order to fully capture and treat the actual needs of their patients.
So if you are trying to educate family physicians on HCC coding, this Crash Course is a great place to start. As always, the M.E.A.T. criteria must be met in order to properly diagnose and accurately code any diagnosis.
And here are the clinical vignettes presented in the AAFP’s HCC Coding Education Crash Course for Family Physicians:
Risk Adjustment Scores vs. Optimized Risk Adjustment Scores in Common Primary Care Encounters
Family Physician HCC Coding Example #1
Patient with DM II presents for routine follow-up. A1C 8.3. Also has stable COPD, oxygen dependent. O2 DME papers signed earlier this year.
ICD-10
Description
RAF
ICD-10
Description
RAF
J44.9
COPD
0.328
J44.9
COPD
0.328
E11.9
DM Unspec
0.118
Z99.81
Oxygen Dep
J96.11
Chronic Resp Failure w/ hypoxia
0.318
E11.65
DM w/ hyperglycemia
0.318
Total risk=
0.446
Total optimized risk=
0.964
Family Physician HCC Coding Example #2
68 y/o patient with hypertension and hyperlipidemia and BMI 37.2. Has been using CPAP for years.
ICD-10
Description
RAF
ICD-10
Description
RAF
I10
Hypertension
I10
Hypertension
E78.5
Hyperlipidemia
E78.5
Hyperlipidemia
G47.33
Sleep Apnea
G47.33
Sleep apnea
Z68.37
BMI 37.0-37.9
E66.01
Morbid Obesity
0.273
Total risk=
0.00
Total optimized risk=
0.273
Family Physician HCC Coding Example #3
Patient with diabetes and polyneuropathy. Right great toe amputated several years ago. He continues to smoke. Patient brought in multiple records from other providers. In addition to refill of meds, you counseled for 5 minutes regarding smoking cessation. You spend 35 minutes reviewing and summarizing the outside records and include that in the visit note.
ICD-10
Description
RAF
ICD-10
Description
RAF
E11.9
DM Unspec
0.118
E11.41
DM w/ polyneuropathy
0.318
F17.219
Nicotine dep/cig
F17.419
Nicotine dep/cig
Z89.412
Acquired loss L great toe
0.588
Total risk=
0.118
Total optimized risk=
0.906
Family Physician HCC Coding Example #4
Patient with HTN comes in for upper respiratory infection. Remote history of colon cancer and now has a chronic colostomy bag. DME orders signed earlier in the year.
ICD-10
Description
RAF
ICD-10
Description
RAF
J06.9
Upper Respiratory Infection
J06.9
Upper Respiratory Infection
I10
Hypertension
I10
Hypertension
Z93.3
Colostomy status
0.651
Total risk=
0.00
Total optimized risk=
0.651
Family Physician HCC Coding Example #5
76 y/o presents with swelling of the left arm, redness, and pain. He takes warfarin for atrial fibrillation. He is also a liver transplant patient. Given IM ceftriaxone. PT/INR and CBC ordered.
ICD-10
Description
RAF
ICD-10
Description
RAF
L03.114
Cellulitis of L upper ext
L03.114
Cellulitis of L upper ext
I48.91
Unspec afib
0.295
I48.2
Chronic afib
0.295
Z79.01
Long term anticoag therapy
Z97.4
Liver transplant status
0.891
Total risk=
0.295
Total optimized risk=
1.186
Family Physician HCC Coding Example #6
Patient for follow-up of major depression, improving. New med started 6 weeks ago.
ICD-10
Description
RAF
ICD-10
Description
RAF
F32.9
Major depression, single, unspec
F32.1
Major depression, single episode, moderate
0.33
Total risk= .000
Total optimized risk=
0.33
When educating doctors on HCC coding, be sure to avoid common HCC coding pitfalls by remembering these rules:
• Use documentation and coding to capture the severity of illness/risk of high cost
• Make sure that you capture the complexity of the patient
• Major issues need to be captured at least once a year (clock restarts Jan. 1)
To access the full AAFP HCC Coding Education for Family Physicians Crash Course, Click Here.
Need a real solution to train your family physicians on HCC coding for value-based care?
While this crash course is a great place to start, family physicians prefer to learn HCC coding and documentation for Risk Adjustment in the DoctusTech HCC coding education app. It is the only tool that consistently ranks #1 with both physicians and operators. Demo the app today.
Requiring clinicians to learn one more thing—especially when HCC coding does not feel connected to treating patients—is a big ask. Expecting them to learn in ways that are both ineffective and profoundly dull is just plain cruel.
Doctors talk a lot about behavior change in patients. But behavior change in doctors is incredibly tricky to effect. But to make Value-Based Care actually work, behavior change has to happen at the clinician level. Is it any surprise that asking doctors to sit in a classroom (or on a Zoom call) for an hour to be lectured on HCC coding is both wildly unpopular and not actually effective?
The importance of clinicians mastering HCC coding cannot be overstated. Without proper coding and documentation, Value-Based Care will fail. So we need doctors to understand Hierarchical Condition Categories: how to use them, when to use them, which ones to use and for what. And ultimately, why.
You cannot treat what you do not diagnose.
(And you cannot diagnose what you do not document.)
(And you cannot document what you don’t know.)
While we acknowledge that HCC coding lectures do result in limited initial behavior change, doctors inevitably regress back to the mean. They return to doing what they already know.An email blast with the code of the month has even less impact than a lecture. And even the “gold standard” of one-to-one coaching returns a much smaller lasting impact than the time required to conduct the coaching.
Onboarding a new clinician with zero HCC knowledge can be as daunting as moving established providers into Value-Based Care arrangements.
So what is the answer? If the gold standard only makes a small dent in the needed fund of knowledge, and classroom learning is only marginally effective at short-term behavior change—and email blasts are worth less than the paper they’re not printed on—is all hope lost?
Please allow me to introduce you to the DoctusTech HCC Coding Education App.
Five reasons you should try this app for your team:
Do something different. If you are doing what the rest of healthcare has done for years, your approach is not likely to be any more effective. Ask your CDI team. Ask your doctors. Ask your Director of Quality. It’s time to try something new. Our app teaches HCC coding in a new, fresh way that doctors actually enjoy. We use the socratic method, the same technique used when studying for boards: clinical vignettes.
Timing matters: act fast, learn fast. By not embracing HCC coding fast enough, your VBC contracts are not generating the revenue they need to. And in order to support clinicians and patients, you need to learn and adopt – faster. The in-app lift requires less time than microwave popcorn, per week, and delivers real-world behavior change right away. Our app is fast.
Money matters. Patient care is directly related to revenue. Revenue is directly related to RAF accuracy. And RAF accuracy is downstream from HCC knowledge. Invest in your clinicians, change behavior, capture and document new diagnoses, boost RAF accuracy. It all starts with changing the behavior of your doctors. Our app changes behavior.
Happy doctors practice better medicine. By using a tool they enjoy, and driving results right away, your doctors will thank you. Our app has a 90+% month-over-month engagement rate across all clients. Our app makes doctors happy.
25 Hours of CME. Learning HCC coding in the DoctusTech app is not only fun and rewarding, it also provides 25 hours of accredited CME per year. So if you are asking your doctors to learn HCC coding, give them the tools they need to succeed, along with a nice 25 hour CME bonus on the side. Our app provides 25 hours of CME.
Humana’s Chief Medical Officer, William Shrank, MD, MSHS, co-wrote a study in March (published by JAMA) titled “Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries.” (Gondi S, Li Y, Drzayich Antol D, Boudreau E, Shrank WH, Powers BW. Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries. JAMA Netw Open. 2022;5(3):e222916. doi:10.1001/jamanetworkopen.2022.2916)
It is a very quick read, but here’s the highlight reel:
Downside Risk vs. Fee For Service
“Compared with FFS, beneficiaries cared for under 2-sided risk models had lower rates of hospitalizations, observation stays, and ED visits.”
“Compared with FFS, 2-sided risk models were associated with a 15.6% (95% CI, 14.2%-17.0%) relative reduction in avoidable hospitalizations, compared with 4.2% (3.4%-4.9%) for all-cause hospitalizations (Figure).”
Upside Risk vs. Fee For Service
“For all outcomes, there was no significant difference in acute care use between beneficiaries cared for under upside-only risk models and FFS.”
Further Discussion
“In this study of MA beneficiaries, advanced value-based payment arrangements (ie, 2-sided risk models) were associated with lower rates of acute care use, especially those events that are potentially avoidable. These findings are consistent with evaluations of value-based payment in traditional Medicare and serve to expand the evidence base around value-based payment models in Medicare Advantage.1 The lack of significant differences between FFS and upside-only risk models suggests that downside financial risk may play a key role in effective value-based payment arrangements.”
This study had limitations.
Stephen Kemble, MD (Queen’s Medical Center, Honolulu) and Gordon Moore, MD, MPH (Professor of Population Medicine, Harvard Medical School, Boston, MA) both brought up valid concerns in the comments section, calling out the potential for selection bias, and even asserting that the study does not answer the question it purports to address.
Obviously, there is more to learn. But what do you think? Is the data telling you that downside risk decreases avoidable hospitalizations? Or is something else at play? And if so, what do you think it is?
A guest walks into an upscale hotel and unburdens himself of several suitcases into the waiting hands of an eager bellhop. When both arrive at the room, rather than giving a tip, the guest offers a hearty thanks! With a dry smile, the bellhop frankly states, “‘Thank you’ don’t feed the bulldog.”
And he’s right. For all the talk of improving outcomes and reducing costs, it takes money to provide the kind of care that truly improves outcomes. But in the same breath, caring for the health of a population is very clearly not about the money. So how does a $4+ TRILLION-with-a-T industry improve outcomes and reduce costs while balancing on the razor-thin line that both is and is not about the money?
In the Value-Based Care space, the full risk model is often called the “silver bullet,” AKA the only thing going that is trending toward a sustainable solution. Full risk is, in fact, all about the money: how it is deployed, where it is directed, and what mechanisms are in place to either gain or lose the money.
(But also, it’s not about the money.)
Provider groups are not jumping ship from their traditional fee-for-service model into full risk because each clinician in the group finds herself in need of a new boat. The transition from FFS to VBC is driven by that same spark that drew optimistic kids out of college and into medical school: the desire to help people.
And nothing helps people stay healthy like a full risk model, or as it’s known in some corners of the world, “Mutual Assured Destruction.”
The HCPLAN’s annual report (Health Care Payment Learning & Action Network) shows a slow but consistent rise in dollars spent in VBC arrangements, and a glacially slow (but steady!) decline in dollars spent in FFS arrangements.
The proof is in the pudding. And the pudding is made out of data. Humana’s Chief Medical Officer, William Shrank, MD, MSHS, co-wrote a study in March that seeks to answer the correlation between avoidable hospital visits and models of payment and risk. Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries(Gondi S, Li Y, Drzayich Antol D, Boudreau E, Shrank WH, Powers BW. Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries. JAMA Netw Open. 2022;5(3):e222916. doi:10.1001/jamanetworkopen.2022.2916).
In that piece, we see the smoking gun that fired the silver bullet that is gradually improving outcomes and reducing costs:
Compared with FFS, beneficiaries cared for under 2-sided risk models had lower rates of hospitalizations, observation stays, and ED visits. For example, the adjusted rate of ED visits per 1000 patients for 2-sided risk models was 375.8 (95% CI, 370.9-380.7) compared with 434.1 (95% CI, 426.5-441.9) for FFS. For all outcomes, there was no significant difference in acute care use between beneficiaries cared for under upside-only risk models and FFS.
The association between value-based payment and decreased acute care use was most pronounced for measures of avoidable acute care use. Compared with FFS, 2-sided risk models were associated with a 15.6% (95% CI, 14.2%-17.0%) relative reduction in avoidable hospitalizations, compared with 4.2% (3.4%-4.9%) for all-cause hospitalizations
So in a fair fight, when it comes to reducing avoidable hospitalizations, full risk—or 2-sided risk, downside risk—beats both FFS AND shared savings by a healthy margin.
You have probably heard the phrase “the fear of pain is a greater motivator than the desire for pleasure.” Freud, Maslow, and even Psychology Today speak to this, but very few examples illustrate the principle so vividly as when comparing upside risk or “shared savings” (a reward) against 2-sided risk models (full risk, AKA the opportunity to lose money).
This is also known as “aligning incentives.” Simply put, if Jerry stays healthy, Jerry’s doctor keeps more money, but if Jerry takes a costly trip to the ED (Expensive Department), his full-risk-bearing healthcare provider pays the piper.
While Jerry may be motivated to keep his diabetes under control and stick with his medication, his provider is financially incentivized to do all of the things that reduce those avoidable hospitalizations.
Beyond the annual wellness visit, there are myriad things that are shown to reduce those acute events. Send Jerry home with a remote patient monitoring device and assign staff to monitor the results. Call Jerry to ensure he’s doing okay. Ensure he has transportation to and from the clinic. Offer other services in clinic to make Jerry want to come for a visit. (Looking at you, Florida, with the haircuts, mani-pedis, fresh produce, mental health counseling, and full-time massage therapist, all at no cost to Jerry.)
Obviously, in the relationship between money and healthcare, it’s complicated…. But by shifting risk in the direction of providers, the data show that avoidable hospitalizations are less and outcomes are improving, which directly impacts cost of care.
In Friday’s “State of the Department” address, HHS Secretary Xavier Becerra spoke candidly about upcoding and overcharging in Medicare Advantage. After offering prepared remarks on the continuing COVID public health emergency, Robert King of Fierce Healthcare asked very pointedly about upcoding in Medicare Advantage. Secretary Becerra answered with few specifics, but a clear directive that upcoding, overcharging and costs within Medicare are very much a priority of the department.
“All those things are being examined…
We’re going to get our money’s worth for Americans.
– Xavier Becerra, HHS Secretary
>> Robert King: Hi, Robert King with Fierce Healthcare. Thanks so much for taking my question.
Robert King of Fierce Healthcare asking HHS secrertary Xavier Bacerra about upcoding and overcharging Medicare Advantage
I want to talk to you about the Medicare Advantage program, which has grown a lot in popularity, but it has undergone criticism from progressive lawmakers about risk adjustment tactics like upcoding, which is leading to Medicare overpayments.
Do you share those concerns? And if so, what actions is HHS doing to kind of alleviate these issues?
>> Xavier Becerra: Robert, great question, and thanks for asking a question that seems to be a little bit different from some of the others.
HHS secrertary Xavier Bacerra responding to Robert King of Fierce Healthcare asking about upcoding and overcharging Medicare Advantage
So, Medicare Advantage started as a program where we were told by the plans that are offering Medicare Advantage that they could provide as good a level of services health care to seniors on Medicare as the existing traditional system of Medicare, what we call a fee for service, but for a better price.
So it was going to be a good deal for Medicare recipients to have access to good health care services through a Medicare Advantage plan, and it was going to be a good deal for the taxpayers because we would save money in the process.
So far, from what I understand in the evidence, the data, it shows that we spend more per Medicare recipient through the Medicare Advantage program than we do through the fee for service program for Medicare recipients.
We have seen some evidence that in certain areas there seems to be charges that go beyond what would be necessary.
You mentioned the upcoding, which means that a provider will say that they provided a service that is greater or more intense than what was actually needed by the patient, and therefore they get a higher level of reimbursement.
All those things are being examined. There is clearly evidence out there on a lot of these things, and we are taking a close look at how we can make Medicare, writ large, work for Americans and for taxpayers.
We’re going to get our money’s worth for Americans.
We want to make sure that every American senior, every American who receives Medicare, gets what they deserve. Americans work really hard for their Medicare, and so we want to make sure it’s there for them. We don’t want anyone overcharging seniors or any other Medicare recipient for services, and we don’t want taxpayers to be duped.
And so we’re going to do everything we can, whether it is Medicare Advantage or Medicare fee for service to make sure that we’re getting our money’s worth.
And with that, Secretary Becerra concluded the press conference. While no specifics were given as to just what exactly HHS and Secretary Becerra have planned, it’s clear that the concerns about upcoding, overcoding, and overcharging in Medicare Advantage are clearly in their sights.
We recently ran a poll asking how doctors preferred to learn about HCC documentation training tools and resources, and 50% selected “Peer Recommendations.” Fortunately, doctors just like you are using and loving our platform, and eager to share their experiences. We’ve broken their testimonials into three categories: Ease of use, Depth of learning, Accuracy, and Quality of education.
“There are a lot of other programs out there, but not like this.” – Dr. Jose a Villaplana-Canals, MD
“Providers are not going to be able to do this much longer without tools. Even the Cadillac of EMRs has its limitations, and you’re never going to get away from provider education; it’s necessary.” – Teresa Caniglia, CDI
1. The format is easy and convenient to use
HHC coding education right on your phone makes it easy to learn, anytime, any place. Unlike lectures or even one-on-one coaching, the simplicity and convenience of the app allow you to engage in ongoing training throughout the day. Although, it only takes about 5 minutes per week to stay up to date!
It’s an easy format to follow. The mobile app is really easy to use and launch. It’s nice just having it with you rather than trying to read an article or listen to a podcast. . – Dr. Joseph Bateman
The mobile app is wonderful in that it’s a clinical vignette – it’s what is literally in front of their face, and it gets them thinking. – Teresa Caniglia, CDI
It’s nice. You know, I’ll be sitting down to eat something, or I’ll be sitting in a waiting room somewhere waiting to go to my doctor, physical therapy, whatever. Then I’ll just pull the app up, and I’ll do, you know, five or ten questions, click and shut it down, and you go do your thing. – Dr. Joseph Bateman
The app seems easy to use. – Dr. Jeffrey Linder
2. Clinical Vignettes increase memory and insights
Deep learning isn’t just about getting the information, it is about knowing what to do with that information. The DoctusTech App helps you learn through challenging questions that reveal gaps in knowledge and explanations that deepen understanding.
I like the concise feedback you get when you get a question wrong. And it tracks your progress. Looking at the right answer and why it’s the right answer – that’s very, very helpful. – Dr. Joseph Bateman
And yes, you miss questions, but that’s how you learn. And you can read afterward the rationale for the answers, and you learn right there. – Dr. Jose a Villaplana-Canals, MD
Our app also incentivizes ongoing learning by gamifying the process of growing in your knowledge of HCC coding. You can compare results within your organization and determine where your organization lands externally with all users.
I like to be challenged, and that’s the way I learn – because it makes you remember. – Dr. Jose a Villaplana-Canals, MD
It’s concise, challenging, and when you find yourself between 2 answers, it’s challenging and makes you think! – Dr. Jose a Villaplana-Canals, MD
The app also helps with knowledge retention in ways that are impossible with lectures and books alone.
And I also liked the fact that the information key principles are continuously repeated and asked in a different way. So you really get to know the concept. And it becomes more intuitive for you when you’re working on a patient’s chart. – Dr. Joseph Bateman
When you’re seeing patients, you remember the questions, and you remember what you need to ask the patients. – Dr. Jose a Villaplana-Canals, MD
This highlights your knowledge and what you do or don’t know. The detailed answers help me to understand why it’s the right answer – Dr. Cynthia Ambler
3. The information is current and up-to-date
You need current, relevant and up-to-date information. The best way to stay up to date on all the changes in HHC coding is by regularly engaging with the Doctus Tech App.
You’re never going to be able to teach them everything they need to know in 60-90 minutes. This is never going to be a one-and-done. Medicine is broad, and it’s changing and developing. – Teresa Caniglia, CDI
It is definitely up to date. Any educational program helps physicians prep for boards, so this is a board question format. And that helps. – Dr. Jose a Villaplana-Canals, MD
As the body of knowledge grows, surely the use of digital tools is going to become pretty normal. – Dr. Joseph Bateman
I learned so many interesting things that I didn’t know I should look for. – Dr. Vljayalakshml Thota
4. The format is designed for learning
The DoctusTech App is designed to help you navigate the complex and changing world of HHC coding. The aim of our app is to replace boring lecture-style learning with engaging, challenging, and on-demand learning through questions that test your knowledge while filling-in knowledge gaps.
Question prompts are long, but I learned a lot. – Dr. Laura Tagle
It’s changing the way I’m thinking and how I’m going to document. I wasn’t consistent before this training. It’s an essential self-improvement exercise. – Dr. Patrick Towne
Content looks like my patient population. I’m trying to apply what I learned to my documentation now because it directly relates to my patient care. – Dr. Steven Lobue
Those of us in the know and leadership understand the importance of this and how it’s going to play an increasing role in our ability to deliver, to get paid, to deliver complex care. I personally understand how important it is to have someone use this versus another form of learning. I feel is that this is more intuitive and is full of kind of “aha” moments. All of my other education on this topic hasn’t really been that iterative or intuitive. I think this is the best thing I’ve come across to teach us some of the basic tenants. I got more out of it than I anticipated. I think you underpromised and over-delivered. – Dr. Joseph Bateman
CMS recently unveiled their replacement for the Direct Contracting Model (DCE), renamed now as the ACO REACH Model. Many of the original Direct Contracting Model tenets will remain the same, with a few significant changes announced.
From heightened scrutiny on up-coding and documentation accuracy to improved Access and Equity, the new model looks to improve upon DCE without replacing it entirely.
Download the full CMS webinar presentation deck, and read our interpretation of the new guidelines.
Levi Wiggins: Alright. Here we are. Live with Dr. Kazi for Year End Preparation for 2022: things to stop doing, things to start doing and things to keep doing. Our host, as always, is Dr. Kazi. Give us a brief introduction!
Farshid Kazi, MD: Thank you everybody. Farshid Kazi, internist by training, with a palliative care focus, then hospitalist, outpatient doctor, and kind of grew up in the value-based care system. And now I’m here with DoctusTech.
Levi Wiggins: All right now, I want to jump right in. So we’re going to start with things to stop, what to start its place. And when we get to the end, we’re going to talk about some things to continue.
So the first bad habit of VBC and HCC documentation to break in 2022 is the 60 minute lectures once or twice a year – stop doing that. But why Dr. Kazi?
Farshid Kazi, MD: Uh, other than the fact that they’re mind-numbingly boring, and as we all know, we don’t actually retain the information. The data is very clear that doctors don’t have sustained behavior change from it. So if you think about your attention span, post-college, I’m assuming most of you can’t sit and listen to a lecture for 60 minutes anymore.
Nobody can, so why do we keep doing it? Because it makes us feel good. We should stop doing it, call it for what it is. Let’s find a better way to meaningfully engage doctors, teach them about this information, and then hold them accountable. And what that means can vary by organization. It can mean that you’re running some type of test to make sure knowledge retention is happening.
You can do one-to-one coaching, which is still a very meaningful way to give feedback to your docs. But please, please stop doing the one hour lectures—for the sake of your doctors—and start holding them accountable for real knowledge retention through one of many ways. And DoctusTech is one of those as well.
Levi Wiggins: Wait, so you’re saying the 60 minute lectures, just like they do in medical school (sarcasm)! Right? That’s how doctors like to learn, right?
Farshid Kazi, MD: Yeah. I mean, Levi, there’s no magic there, right? So you can teach doctors multiple different ways. Teach them with clinical vignettes. You can teach them with one-to-one feedback. You can even teach them by doing charts and dissections, but what you should not do is put them in a classroom setting for an hour and teach them about ICD 10.
Levi Wiggins: That sounds so boring. Alright. The next bad habit to stop as we roll into the next year: pre-templating notes for doctors with new diagnoses. “Here doc, I think you missed one!”
Farshid Kazi, MD: Yeah, we all do it. Any organization has a lot of different strategies on making it easier for doctors. We get it. Doctors are really busy. There’s a lot to do. But pre-templating notes, giving them the diagnosis, is really frowned upon by CMS and DOJ. And if you haven’t seen our white paper around RADV audits, you should take a look at it, because there really have been some slaps on the wrist saying, look, let the doctors do what they’ve been trained to do, make clinical decisions.
And that should not be by prompting from non-clinicians around new diagnoses.
Levi Wiggins: So the thing to start in place there, uh, improving physician workflows inside the EMR. Tell me more about that without a doctor’s tech infomercial. I’m warning you!
Farshid Kazi, MD: So when we think about how we make that easier for doctors, oftentimes we’re trying to do the work for doctors, but really that’s a heavy lift and the hardest solution. Fix the problem inside the EMR. Find a way to get the data that you have outside of your EMR, into the EMR, and solve for the issue, so that doctors can make clinical decisions while they’re with their patients at the point of care.
Levi Wiggins: Okay. And I’ll go ahead and make the infomercial being the marketing. We have a way to do that. So if you’re trying to break that bad habit, hit me up on LinkedIn.
The next thing is stop the checklists of claims-driven diagnoses without supporting evidence – or start getting in big trouble.
Farshid Kazi, MD: Again, the same slap on the hand that happens from pre-templating notes with diagnosis for doctors can happen when you start putting bad data in front of them. We all know claims data is notoriously noisy and inadvertently inaccurate. And so if you start to put inaccurate data in front of your doctors, hoping that they’re going to be a hundred percent accurate, you’re going to find yourself in a bad spot.
So really, starting to think of, “how do I get the right data in front of the doctors at the right time with meaningful support so they can make a true informed decision” is critical here as far to part of your accurate risk adjustment documentation.
Levi Wiggins: We do talk a lot about that checkbox culture, and that’s not why you help patients. You don’t want to check boxes. You want to help them.
Farshid Kazi, MD: You give the doctors a list of check boxes to go through. Their only mission is to get through that. It’s not to make sure it’s accurate. It becomes really a difficult task for them to do. But if you’re giving them insights, giving them clinical guidelines, and letting them do what they do best—which is make medical diagnoses and treat patients—they will optimize their documentation and it will optimize your risk adjustment score accuracy.
Levi Wiggins: So the start on that is to make more of an effort to get supporting documentation and then provide it to your doctors with any claims data. Does that sound about right?
Farshid Kazi, MD: That’s absolutely right.
Levi Wiggins: So when we look at these organizations that are really forward-thinking, they’re kind of where everybody wants to be. There are a few things we see that they’re doing. And if your organization is doing this, first off, I want to commend you – because you guys are doing the hard work of making this easier for the doctors. Thank you. You guys are heroes.
Ok, of the things to continue in 2022 internal audits. I know you hate it, but there’s so much better than an external audit.
Farshid Kazi, MD: Tell me about it. Yeah, gone are the days of just trying to increase your RAF. That should never be part of the nomenclature. It should not be the talk talk-track for any of your teammates. Really, you need to be thinking about how to make your documentation accurate.
Not only for increasing the proper diagnoses, but looking for inaccurate over-documentation. It happens inadvertently. It happens in every organization and, some of the data is showing somewhere between 5% and 15% of data submitted is inaccurate. So starting to look both ways and telling Medicare, CMS, DOJ: we are doing our best to make sure we’re documenting accurately.
And that’s because we are internally auditing for anything that is over-coding. Give the money back before you ever receive it. So you don’t get into trouble.
Levi Wiggins: That’s absolutely right. And, and it’s partly just an ethical thing. Partly it’s an administrative thing, but for those of you who are doing those internal audits, you guys are true heroes.
Levi Wiggins: OK, the next thing to continue for 2022 is accountability for your doctors!
Farshid Kazi, MD: Yeah, too often, we start to, to spread ourselves thin. Everyone’s doing everything. It’s a team approach, but really, who’s going to be held accountable for the knowledge game? How do we make sure the doctors have retained information to be accurate and compliant with their documentation?
We need to show some type of effort and accountability. And again, thinking through this is not easy to do, transitioning from a fee for service model to value-based care requires a massive change – and dovetails into a few other things that good practices are doing. But really, having a tracking dashboard, showing that it matters.
And then giving feedback to your doctors is critical around that.
Levi Wiggins: Now this one, to be honest, I don’t really know what this means. What I want you guys to continue is time allotments and you and I are both going to find out what this means now!
Farshid Kazi, MD: Documenting accurately takes some time. And so if you’re going from a predominantly fee for service driven model to a value-based care driven model, you need to get C-suite buy-in to have commitment on increasing time of visits, giving doctors time to document accurately. So they’re not trying to get done quickly, working in the car, at home on the weekends, or even worse – while they’re with family.
It’s giving them time to document accurately and change the schedule – it has to be done with intentionality. You cannot fit the same model of value-based care into fee for service and expect something totally different when it comes to outcomes.
Levi Wiggins: Oh, that makes perfect sense!
OK, the last thing we have for those of you who are doing it, continue, keep up the fight! And for those of you who are not doing it, this is the year to make those changes. Clinically driven ROI. Over to you, David, in the studio!
Farshid Kazi, MD: Levi, too often risk adjustment documentation accuracy is around financials. It’s about the numbers and the dollars coming. Why does that matter? The mission behind value-based care is we’re trying to help reinvest into delivering better outcomes.
And so if you do your documentation accurately, you can invest in the palliative care, you can invest in the tele-health, or remote device monitoring. So show your doctors how that capital is being repurposed towards improving patient care. And all of a sudden you will see buy-in and commitment.
I am a big believer that my colleagues are trying to do the best for their patients, but the infrastructure… The healthcare system was not built to help them succeed. So as you make this transition, if you start to show how you’re reinvesting those dollars, it will have a meaningful impact for your doctors.
Levi Wiggins: That’s great! Now, forgive my naiveté here, but I know we encounter organizations that aren’t doing some of these things. And to me, you know, I’m just over here in my office, doing my own thing. Help me understand why some organizations aren’t embracing these things, they should start still doing the things they should stop.
Is it, is it budget? Is it time? Is it sloth and human frailty? What is it? Lack of resources? What’s what stops an organization from doing the things they should do – this list that they know they should start and stop and continue?
Farshid Kazi, MD: Can I say, all of them, Levi? Is that a cop-out answer? I mean, it could be any number of those, right? But there’s no question. If you look at this list, things we’ve talked about, they should be hopefully obvious and things that you should do. And yet 80% of the groups we talk to do some combination of the things we’re asking people to stop. It’s clear as day that the DOJ has a high degree of focus on documentation accuracy, as does CMS.
And so, right now is the time to start thinking about how you stop this. You get your C-suite, buy-in have physician champions and try to do this the right way from the get-go.
Levi Wiggins: And this can all be done… every single one of these can be done without ever booking a demo of our tools, talking to us – like, you don’t need us to do this stuff, right?
Levi Wiggins: Obviously we help, we help automate a lot of these processes. Am I Canadian? I just said “PROcesses.” So I’m probably Canadian. Anyway, we do make it easier, but they can do it without us. Right?
Farshid Kazi, MD: A hundred percent. The purpose of this is so that it makes you feel a little bit uncomfortable and saying, Hey, let’s try to do 2022 better.
And yes, we, a hundred percent can help. And that’s why we built DoctusTech, but you don’t need us. You don’t need a vendor to do this. You can really start to do this with the resources you have without spending a single dime.
Levi Wiggins: But also, DoctusTech: solutions for people like you who need to stop doing things they did last year and do different things in 2022!
Levi Wiggins: All right. That’s a wrap! Ok, to sum it up, here’s the full list:
Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.
CMS released its final Medicare Shared Savings Program rule, called “Pathways for Success” for ACOs. The new rule is designed to help establish a path toward risk, with a heavy focus on Risk Adjustment Coding.
CMS = Centers for Medicare & Medicaid Services || MSSP = Medicare Shared Savings Program || ACO = Accountable Care Organization
MSSP lays out a clear transition to risk, and allows ACOs to start at different points, depending on where they are as an organization. Also, it extends the agreement period from 3 to 5 years, which provides more time to measure performance against the benchmark. This creates a Basic and Enhanced track option en route to risk. (See Image A below)
Image A Basic & Enhanced Tracks
Risk Adjustment Coding Basic & Enhanced Tracks
There are several best practices an ACO can adopt to help succeed within the new model. Many ACOs are now looking toward Risk Adjustment which not only allows highlighting of high-risk patient populations, but will also provides a more accurate way of predicting cost and determining reimbursement.
The adoption of HCC risk adjustment best practices has been recognized by Medicare Advantage plans for several years. In contrast, ACOs who participate in Medicare Shared Savings Program (MSSP) have opted away from any type of program, as they felt it had little effect on their benchmark. This is often due to an ACOs past experience within the MSSP. However, the new changes open many doors to those who may have shied away from risk in the past, for reasons such as:
Benchmarks were based 100% on an ACO’s historical success.
No adjustments were made on the true risk score of the beneficiary, thus no penalty for similar low risk scores year over year.
False/inaccurate predictions of condition profiles of beneficiaries.
Re-enrolled beneficiaries given a demographic adjustment only, making it very difficult for an ACO to improve coding and increase benchmarks.
Given the new Pathways to Success Rule, ACO groups are being shown risk adjustment in a different light. There are no more restrictions on RAF changes for the historical beneficiary. Instead, there is a 3% limit on the total increase from historical to performance year.
ACOs continue to lag in adoption of HCC coding practices. From the most recent 2019 Shared Savings PUF file, 49% of groups have seen a drop in RAF from benchmark year 3 (BY3) to Performance Year (PY1). RAF scores on these groups dropped from 1.0149 within BY3 to .9819 in PY1 on average, showing a -3.25% drop (see below in Image B). As a result, ACOs could have faced a significant uphill battle over the next few performance years as they attempt to true up their future benchmarks. This is one significant issue addressed by MSSP.
Image B: RAF Decrease PUF file 2019 ACO MSSP
Coding improvements are capped at 3%, however, with this drop (shown above) from BY3 to PY1, RAF improvement can actually be significantly above the allowed 3% to offset the drop of -3.25%. Therefore, now is the time for ACOs to begin adopting HCC Risk Adjustment best practices to help in this effort.
By adopting best practices within HCC coding, you can ensure that your medical group has the highest specificity of diagnoses, ensuring quality of care and compliance.
What exactly are these best Risk Adjustment Coding practices that can be adopted?
Educating Providers
Making correct preparations prior to encounter
Documentation of all chronic conditions that are current
Ensuring a clean clinical workflow to display conditions for clinicians
Post-encounter review for quality assurance
As value-based care is being adopted on a wider scale, the old model of Fee for Service payment is slowly dwindling. More time is being spent with a patient to treat all chronic conditions at the encounter is becoming best practice.
One of the major issues that medical groups contend with is the ability to use all relevant data to create an aligned clinical workflow that helps the physician recapture, diagnose, and reject any conditions which are inaccurate. A melee of data is combined in the form of claims data, RX data, member eligibility, historical diagnosis, and utilization. The ability to organize this data into actionable insights, clinical suggestions, and quality opportunities is a huge task for any ACO.
Here at DoctusTech, we can offer a solution to this issue…..
Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.
DOJ vs Sutter Health – any time you see DOJ vs. Anybody, there is trouble brewing. But when it is a provider group, that looks like a sea-change. Live with Dr. Kazi is a new video series from Value-Based Care expert, Farshid Kazi, MD – Co-founder of DoctusTech, and passionate advocate for HCC coding and the Quadruple Aim. In this episode, Dr. Kazi shares insights and perspectives on the landmark case and what it means for the future of healthcare.
Watch the full interview here!
I’m Farshid Kazi, co-founder of DoctusTech and an internist by training with a focus on palliative care.
I’ve built my career on population health out in California.
I’m excited to help other physicians looking to take the journey and leap into value-based care.
Levi Wiggins: On another episode of Live with Dr. Kazi! You are a population health expert & co-founder of DoctusTech. And today we’re going to do a bit of a deep dive into the recent case of the Department of Justice and whistleblower Cathy Ormsby against Sutter Health and Affiliates, with their false claims act violations, alleged, and the $90 Million settlement.
What is the first thing you think when you hear about DOJ vs Sutter Health?
Farshid Kazi MD: It makes me sad. I mean, I think a lot of us providers know that there’s a lot of pressure around documentation accuracy, and it felt like it was a Swiss-cheese effect. I have to think that my colleagues in the field of value-based care are trying to do everything right.
Always trying to be accurate and document appropriately. But sometimes, when you set up systems in piecemeal, there’s not a proper safety net to catch when multiple errors happen, the perfect way. And unfortunately, that was what the situation looks like it could have been at Sutter Health.
Levi Wiggins: I mean, in the, the big 45 page piece that the DOJ released, there were a lot of different parts that got highlighted. And I think we were discussing earlier some of the things that they did make perfect sense, like that’s a good idea, right?
Farshid Kazi MD: Yeah. That’s right. You want to bring in your patients once a year, talk about the medical conditions, talk about what’s happening, make sure that everything’s safe at home.
Really try to plan ahead for the following year. So the concept around an annual wellness visit. Completely kosher. It’s actually encouraged and something that us providers look forward to doing. And oftentimes during those visits, you will document HCC diagnoses. These are things that the patients have.
You want to talk about it with the patients. Tell the plans, tell the Medicare, talk about what their medical conditions are, and also think about what you’re going to do preventatively for that following year. And during that visit, you’ll often document HCC diagnoses, and sometimes programs will provide providers with all the information possible so they can properly document during that visit.
But what you want to do is be careful that you’re not helping increase the up documentation or up-coding and making sure on the backend, everything is compliant. And sometimes if you’re just focusing on the documentation, and making sure the diagnoses are in the chart before claims is submitted and not thinking about the compliance piece, that’s kind of where you can end up in Sutter’s situation.
Levi Wiggins: Now, I read that they set a goal to increase their risk adjustment scores by 28%.It seems a little high.
Farshid Kazi MD: Yeah, nationally, the average is around 3%. When you think about risk adjustment going up every year. And so typically, we never try to tell providers, “we have a target on which we want to increase the RAF.”
It’s more about how do we improve our accuracy. So thinking about both up and down. So if you’re having diagnoses that you’re carrying over that are inaccurate, really trying to empower your providers to say, “Hey, this should not be submitted.” Or “this is inaccurate,” is the right way to think about it.
So, setting a goal of 28%, again, not having been in their shoes. Perhaps it was more around increasing their accuracy and not necessarily increasing the score, which would be a no-no.
Levi Wiggins: And how do you feel about a coder coming in after the encounter and adding a few codes that the clinician may have just simply overlooked.
Farshid Kazi MD: You know, what Sutter had in place is no different than multiple groups across the United States. They have work being done before the patient visit, they have worked being done after the patient visit; coders are an integral part of the team to accurately reflect the work that providers are doing with patients.
And the problem comes when you’re suggesting diagnoses to providers who have not necessarily been educated around why that’s being presented in front of them and given them a workflow that allows them to only check boxes to carry diagnosis over so they can get through the workday.
The key really here is, are you giving the right information, educating the providers and allowing them to make a clinical decision? So when you have a coder coming in and suggesting something that wasn’t necessarily documented at the point of care, it becomes a little bit more of a gray area. And you want to be very clear that your provider understands why they’re being suggested that diagnosis.
And then given the power to say yes or no one, either direction.
Levi Wiggins: We talk about a lot of risk adjustment, but the risk to providers that this case seems to indicate is that not just CMS, but also the DOJ is very concerned – this is the first time I’ve seen the, the word mischarging. Talk about the risk to provider groups, now.
Farshid Kazi MD: Yeah. I mean, this is a whistleblower case, right? So we know that the reason that the DOJ looked at this was because someone raised their arms and said, “Hey, this doesn’t feel right.” RADV audits are another way to prevent abuse of the Medicare advantage documentation compliance programs.
But that right now is focused just on payors. Every time we talk to provider groups, or I speak with a colleague, I’m always trying to encourage them to think about compliance more than RAF accuracy, because it’s only a matter of time with the Direct Medicare Contracting model. ACOs taking downside risk that provider groups who are taking on this risk are going to be held accountable in the same way that a payor is.
And so it’s unfair for us to say, look, we submitted a clinical diagnosis without justification. It’s up the plan to figure out whether we are compliant or not. And then we’re shielded by the plan. So right now, all audits through MA plans are happening at the payor level. But I’m really confident it’s only a matter of time before it starts coming back to us provider groups.
So this, if nothing else, should make people a little nervous, or do they have the right processes in place? Are you educating your providers to understand the “why” around risk adjustment? Am I accurately documenting? Do I have the right justification? And am I given the right amount of time to say yes or no to these diagnoses?
If you don’t have the right information, you should not be carrying over any diagnosis. That is just a yes, because it’s going to make your boss happy or make you get through the day easier. So making sure that conversation is happening is integral to making sure that the next piece- which is compliance- is happening.
Levi Wiggins: So as we kind of peer over the garden wall here into Sutter Health’s dealings, obviously, no admission of wrongdoing was made in a $90 million settlement, but from out here, what do you see that they could have, or should have done differently or better?
Farshid Kazi MD: I think if you think about risk adjustment strategies, when you think about it in a pyramid, the foundation on which you build risk adjustment should really be around empowering, educating, and giving knowledge transfer to providers so that they can make clinical decisions.
So what is it that they’re doing? Why are they doing it? And then what should they do if they see a mistake? And so if that foundation was built, I suspect that the providers would be able to stand up and say, “Hey, some of these diagnosis that you’re putting it in front of me are inaccurate!” And a big mistake that was seen not only at Sutter, that I see across the United States, is acute diagnoses are being carried over year over year.
Meaning things like acute stroke, acute heart attack. That should not be coded in a patient the next year – or a malignancy that’s been resolved. And again, being carried over because someone gave a fax paper or a piece of paper to a doctor and said, can you please check yes or no to these diagnoses?
And maybe the provider thought, “Hey, the patient did have this at some point” But didn’t realize that this is not something that happened this year. And that’s up to, again, building the knowledge around what you’re trying to do. Putting the infrastructure in place so that you’re catching and saying, “Look, an acute diagnosis carried over year over year. Let’s go back to this provider. Did this patient really have two strokes? Two consecutive years?”
Maybe it’s yes. Maybe it’s no, but there needs to be a process around catching that. So I think building knowledge, having point of care workflow to empower your docs and then really building a solid foundation around compliance is going to be key.
Levi Wiggins: That’s good. I like that. One thing that we saw in this specific case is they were accused of intentionally coding unsupported diagnoses, and then finding them and not paying back – on purpose. So when we talk about increasing accuracy, talk to me a little bit about the process. I guess how you run a business, looking at money you’ve you’ve gotten and how to give that back in a way that’s ethical and reasonable.
Farshid Kazi MD: Yeah. I mean, it’s really hard to give money back once you’ve gotten it. So the best approach is really, don’t take the money if you’re not deserving of it. So really making sure that before the diagnoses go to claims, and then go to the payors, and then Medicare, you know, with full confidence, that they actually existed in the patient chart.
So one thing I always coach and work with provider groups is saying, what are the diagnoses that are acute? You don’t want to carry over and make sure that’s a no-no. But the second piece is let’s talk a little bit about, at the point of care. As the doctor’s writing the note, is there a way to catch and make sure that there’s compliance there before you even submit the bill?
And if not, let’s make sure we’re doing some audits and charts to give some confidence to you as an organization that you’re not receiving any reimbursements for diagnoses that are inaccurate.
And then the second piece to that is once you’ve done, that is having a retrospective aspect of let’s do some charts on. Let’s look through this and make sure we’re paying back appropriately because compounded over time. That can be a massive bill as well.
Levi Wiggins: Okay. So as we, as we look into the future here I mean, the whistleblower case is, is one avenue. The RADV audits are another avenue. But I guess what, what is, what is the risk level for, for a doctor? Like, what’s the likelihood of getting caught at this point.
Farshid Kazi MD: Yeah. You know, is something morally wrong only if you get caught, right? We could talk about that forever. But to me, it’s a question of do the right thing. The first time around. I think all providers have gone into the field because of that same level of commitment to their patients.
So if you are in value based care, because you care about delivering better care. And you think you can do it at a lower cost. Risk adjustment is a necessary part of that, but do it right the first time. So document accurately. And I think that the two pieces that provider groups should be worried about is there’s a significant risk to them.
That Medicare is going to now start to audit provider groups as the risk is passed from payors to provider groups. And the two things that I see all the time that providers are doing incorrectly is one, they’re carrying over acute diagnoses. And two, when they’re putting the diagnoses in there, they’re not necessarily justifying it.
They’re being told by their group that, “Hey, these diagnoses might exist. Do you agree?” And in order to move through the day, they say yes, but the diagnosis, maybe technically doesn’t meet Medicare guidelines, or doesn’t meet clinical guidelines. And that is not being audited, right? Yeah. And I don’t think that’s going to be very far off from when Medicare says, not only do you have to be compliant from a technical perspective and the pieces of your documentation, but Hey, the definition of the medical problem needs to be there.
Does the patient really actually have that diagnosis?
Levi Wiggins: So we published the white paper on RADV audits, but the principles from that should be just as applicable to provider groups. And I want to just touch on those. One thing. Our paper determined was the provider behavior is the first thing to fix. And that’s, that’s the education piece.
The next thing we, we determined was that proper documentation fixes nearly everything. You know, you mentioned that if you document something that isn’t, you know, maybe it was well-documented, but it wasn’t clinically accurate- that could spell trouble down the road, but right now, we just really need documentation to be on point.
The next thing we’ve determined is that without the proper tools in place, documentation is nearly impossible to get right. Another thing we did determine that certain codes get used erroneously more than others.
That’s also a very large terrifying gun to the head of a business. Is there anything I missed any any big takeaways we want to make sure we’re sharing.
Farshid Kazi MD: No. I think the whole process of auditing and checking is all limited by human capital.
Right? We don’t have enough hours in the day or people to help us check this, but as we enter into this next digital era of healthcare, where we’re in the midst, Technology can help you do that. Not only can you audit some sample size, but you can have good visibility to your entire patient chart and be able to say with full degree of confidence, that every chart that I’m documenting against has some type of technology or eye that’s been placed on it to make sure I’m compliant and making sure I’m not making a human error, which happens.
So utilizing technology to solve for some of the workflow gaps to solve for some of the knowledge gaps we’ll augment, not necessarily replace the strategies that are good compliant organization has. So making sure you build that in, and then having a clear safety net and allow people to be able to raise their hands, if they feel uncomfortable will be the key to making sure you’re compliant and then have, you know, you know, have good nights of sleep at the end because you’re know you’re doing everything right for the right reasons.
Need to learn HCC coding, and don’t want to sit through another lecture? Click below to demo the DoctusTech app.
Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.
Sutter Health Settles with the DOJ is not a phrase we thought we’d ever see on our blog. We recently published a white paper on RADV audits and the importance of strict HCC compliance. A few weeks later, the Department of Justice announced a groundbreaking $90 million settlement with provider group Sutter Health.
In what looks to be a significant change of direction in RADV audit strategies, the DOJ has prosecuted a physician group.
False Claims Act allegations include “mischarging the Medicare Advantage program” and deliberately failing to pay back known overpayments. As a result, Sutter has agreed to not only a large financial settlement, but also five years of increased scrutiny and audits.
This settlement takes place only months after Sutter settled a much larger antitrust case with the state of California ($575MM according to Fierce Healthcare). For provider groups, this is more than a cautionary tale, it comes with a stern warning.
“Health care providers who flout the law need to know that my office will hold accountable those who pad their bottom line at taxpayer expense.” – Acting U.S. Attorney Stephanie M. Hinds
Acting U.S. Attorney Stephanie M. Hinds
For a group as large as Sutter Health, the $90 million is not much. Sutter received $812 million in payouts from the CARES Act; $900+ million in advance Medicare payments; and last year banked $13 billion in revenue. So all dollars considered, this settlement represents a mere 0.7% of Sutter’s annual revenue. However, for the whistleblower who stands to receive up to a quarter of those funds for her work with the DOJ, this is more than significant, it is life-changing. And for potential future whistleblowers, this case is both a legal precedent and a strong financial motivator.
And provider groups of all sizes need to take notice.
Much of the language in the DOJ’s press release reads more like a scolding than a legal case. As though The United States is not merely alleging financial misconduct, but expressing disappointment with the parties.
“The government alleged that Sutter Health knowingly submitted unsupported diagnosis codes for certain patient encounters for beneficiaries under its care. These unsupported diagnosis codes caused inflated payments to be made to the plans and Sutter Health. The lawsuit further alleged that, once Sutter Health became aware of these unsupported diagnosis codes, it failed to take sufficient corrective action to identify and delete additional unsupported diagnosis codes.”
In short, the DOJ alleges that Sutter deliberately coded unsupported diagnoses, got paid, knew about it, and didn’t pay back the overpayments.
“The government relies on healthcare providers, including those furnishing services to Medicare Part C beneficiaries, to submit accurate information to ensure proper payment… Today’s result sends a clear message that we will hold health care providers responsible if they knowingly provide or fail to correct information that is untruthful.” – Deputy Assistant Attorney General Sarah E. Harrington
No longer are RADV audits only a concern for payors, but providers will be held responsible for their HCC coding and the accuracy of their RAF scores.
“Today’s settlement exemplifies our commitment to fighting fraud in the Medicare program.” – Acting U.S. Attorney Stephanie M. Hinds for the Northern District of California.
From the tone of the DOJ’s own press release, this case is only the beginning.
“The knowing submission of inaccurate information to Medicare diverts funds from this vital health care program, which is a disservice to patients needing care… We will continue to work with our law enforcement partners to protect the integrity of federal health care programs and hold accountable entities who engage in false claims practices.” – Special Agent in Charge Steven J. Ryan for the Office of Inspector General of the U.S. Department of Health and Human Services
This may be the first case of its kind, but if the DOJ is to be believed, this will not be the last.
Also, as a condition of the settlement, no admission of wrongdoing has been made by Sutter Health and their affiliates. “The claims resolved by the settlement are allegations only and there has been no determination of liability.”
DoctusTech co-founder and population health expert Dr. Farshid Kazi will dig deeper into the ramifications of this case, and share resources and methods for avoiding a similar fate on the next installment of Live With Dr. Kazi.
HCC Coding is Good For the Country – in the next installment of Live with Dr. Kazi, the new video series from Value-Based Care expert, Farshid Kazi, MD – Co-founder of DoctusTech, and passionate advocate for HCC coding and the Quadruple Aim. In our third episode, Dr. Kazi shares ways in which HCC coding is good for the country.
Watch the full HCC Coding is Good For the Country Episode here!
I’m Farshid Kazi, co-founder of DoctusTech and an internist by training with a focus on palliative care.
I’ve built my career on population health out in California.
I’m excited to help other physicians looking to take the journey and leap into value-based care.
Levi: All right, we are back with another episode of DoctusTech thought leadership with Dr. Kazi. Hey, Dr. Kazi, how you doing?
Farshid Kazi, MD: Hey, Levi, doing well.
Levi: Today, I want you to talk about how, value-based care is generally good for our nation, the United States of America.
Farshid Kazi, MD: Yeah. The main thing people think about when it comes to healthcare is how do I one have lower premiums each month and have better outcomes.
But at a macro level, when we think about costs of care, that rises for a number of different reasons, but when it comes to value based care, you can solve both the personal side and the macro side. As long as we reinvest into taking care of our patients who are at risk for the highest chronic conditions, we’re going to do better as a country.
And a lot of that stems from giving patients choice and involvement in healthcare, which a hundred percent we stand behind. It doesn’t matter what field of medicine is. But sometimes having a clinician, that’s going to be able to spend a little bit more time to educate you, to teach you about the right definitions and what the decisions you have in front of you will allow you to make One) better decisions for yourself; but Two) more affordable decisions for the country.
And sometimes more is not better. And oftentimes when we think about your loved one, your grandma, your significant other even a child sometimes more is not better. That means tests, surgeries, exams, and a good clinician should be able to guide you through that. So from our country’s perspective, value-based care aligns incentives, performs better. And overall from a country’s perspective, you’ll have better outcomes.
Levi: Okay, one thing we talk about in the industry is the quadruple aim. And it seems like that is something that the value-based care HCC world can almost in one shot solve. Can you, can you speak to that?
Farshid Kazi, MD: Yeah. And I think we’ve broken this up nicely and some of the segments we’ve talked about already, right?
How do we make life better for your patients. So better care for individuals. How do we make a better care for all of the US, which is better population health and do that by lowering costs? I think sometimes the equation misses, and this is where quadruple aim comes in is how do we improve lives and balance for physicians?
So you have better care for patients, better care for the country at large or a population health perspective, better work-life balance for clinicians at lower cost.
Levi: And how do we fix that?
Farshid Kazi, MD: Yeah, I think you, you have to start with aligning incentives, right? And so when you think about the categorical shift, that payment happens through fee for service or your traditional model to value based care, where now clinicians are paid for outcomes.
All of a sudden you’ve aligned everything, patient outcomes to physician work-life balance, to lowering costs, and then better care for the population at large.
Need to learn HCC coding, and don’t want to sit through another lecture? Click below to demo the DoctusTech app.
Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.
HCC Coding is Good For Providers – up next on Live with Dr. Kazi, a new video series from Value-Based Care expert, Farshid Kazi, MD – Co-founder of DoctusTech, and passionate advocate for HCC coding and the Quadruple Aim. In our second episode, Dr. Kazi shares ways in which HCC coding is uniquely good for doctors.
Watch the full HCC Coding is Good For Providers episode here!
I’m Farshid Kazi, co-founder of DoctusTech and an internist by training with a focus on palliative care.
I’ve built my career on population health out in California.
I’m excited to help other physicians looking to take the journey and leap into value-based care.
Levi: Hey, Dr. Kazi, we’re back with another episode of doctors tech thought leadership.
So today we want to talk about. Value-based care, as it, as it relates to specifically benefits to the doctors, how is this good for you and your associates?
Yeah. I think as a provider, Levi, we in the fee for service world or the traditional sense of healthcare, get paid only when a patient can come in for a billable diagnosis.
I can have you come in because you’re sick, and bill the insurance company. They say, here you go, Dr. Kazi, which is great, but there’s so many aspects to keeping patients healthy that are not billing. Worrying about your diet, worrying about loneliness, worrying about your mental health.
And some of those components, I, as a clinician, wish I had either the time or the reimbursement to reinvest into your care. So as physicians are starting to transition into value-based care, They are now being reimbursed to care for their patient in a holistic way. And those are, I think, fundamentally the reasons all of us clinicians—it doesn’t matter what specialty you’re in—went into medicine, is how do I make sure that I make you healthier over time?
And so value-based care allows me to do that, which is quite relieving in, in many ways.
HCC Coding is Good For Providers Financially
Levi: Now there’s, there’s the compassionate doctor side of the equation. And then there’s the aligned financial incentives side of the equation.
So as a physician owner, why is this good for you? Risk sounds risky. How does this work?
Dr. Kazi: Yeah. So everyone should not be taking risk upfront, which is a spot-on. It does sound risky, but if you want to practice medicine the way we all thought we would like to, when we were kids, value-based care is the right space to be in.
You don’t need to worry about the number of patients that you need to see every day. You need to worry about what their clinical outcomes are and by clinical outcomes, it means are they going to the hospital? Are they going to the ER, are they taking care of themselves? Preventatively?
And from a financial perspective, you’re getting a set run-rate on your revenue each year. So you don’t have to worry about how do I get my patients to come in, to see me. I’m rather getting a set budget that I can take care of my patient population.
And the ones that are sick and that you have a good relationship with, you’re going to be able to bring in more often than you would have been allowed in the traditional model.
So it helps you financially control your revenue. It helps you control your day to day. Decreases the burden of needing to see a ton of patients, which is why – number one reason people are burning out these days.
Levi: That makes sense. Okay. So at the risk of saying something that we would have to cut from this video later it seems like there’s potential financial upside for providers who enter into risk sharing contracts and code really accurately and document everything.
It seems to me that a doctor or practice could make more money and take better care of patients. Is that reasonable or is it, is it more profitable to just do fee for service?
Dr. Kazi: Yeah. It depends right? The clear answer is, it’s better to deliver good care and make profit, which is a hard thing to say.
And the traditional model, if you’re seeing 30, 40 patients a day, it’s really hard to stand by and say that you’re going to have better outcomes. And in fact, if you look at the data around. Patients that are in traditional Medicare versus patients who are Medicare advantage. They consistently outperform our quality metrics, meaning preventative screenings hospitalizations, total cost of care, which is just a reflection of outcomes on a clinical perspective.
So if you think about just where do you get your biggest bang for buck? It is on the value-based care side.
From a revenue perspective. Yes. If the doctor is taking better care of their patients, they will make more money, but that’s the right model of payment. Not necessarily just seeing more patients because you happen to be churning through a lot of sick patients.
HCC Coding is Good For Providers When They Work With Us
Levi: That makes sense. And just to put a, put a little commercial break onto this: On average, what do we see from a DoctusTech perspective on increased reimbursements when coding is done correctly and recapture rates are at 95%, what does that look like per doctor, per year?
Dr. Kazi: And that could look… it depends on the contracts and they vary quite a bit, but you can look at five to six figures, per doctor per year, on top line revenue increase- if you’re just appropriately documenting.
And that’s, again, not talking about up-coding, we’re not talking about making sure you’re increasing a panel, but you should get paid for doing all the hard work you are.
And that is done through better documentation, which is where DoctusTech helps.
Need to learn HCC coding, and don’t want to sit through another lecture? Click below to demo the DoctusTech app.
Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.
Battling Physician Burnout is a top priority. One pillar of The Quadruple Aim is to Improve the clinician experience.
Even before the COVID crisis, Physician Burnout has been a growing concern. And after 18 months of increased workload and stress, the problem is getting worse, not better.
The Joint Commission Journal on Quality and Patient Safety recently released a study on the relationship between cognitive task load and providers’ ability to perform their job well.
The short version: a 10% decrease in Physician Task Load (PTL) lowers the odds of experiencing burnout by 33%.
The specialties with the highest PTL score were emergency medicine, urology, anesthesiology, general surgery subspecialties, radiology, and internal medicine subspecialties.
It had been theorized that personal vulnerability could be at the root of the physician burnout crisis, but the data do not support this. The JCJQPS used cognitive theory and workload analysis to conduct cutting-edge research, and their findings are both compelling and academically rigorous.
“We evaluated the cognitive load of a clinical workday in a national sample of U.S. physicians and its relationship with burnout and professional satisfaction,”
– Elizabeth Harry, MD, SFHM, coauthor and Hospitalist at University of Colorado at Denver & Aurora
While the study did point to workload as the smoking gun quadruple-aimed at the heart of physician burnout, it did not shed much light on how to reduce that workload, and ease the bourdon of burnout. Several of the coauthors have more to say on that topic.
“Deeper evaluations could follow to identify specific potential solutions, particularly system-level approaches to alleviate PTL… In the short term, such analyses and solutions would have costs, but helping physicians work more optimally and with less chronic strain from excessive task load would save far more than these costs overall.”
– Dr. Colin P. West, Coauthor, Professor and Researcher at the Mayo Clinic.
At DoctusTech, we are eager improve all four pillars of the Quadruple Aim.
Like you, we believe that value-based care has the potential to be a massive lever to improve clinical outcomes, population health, cost and clinician experience. (Yes, VBC touches all points of the Quadruple Aim!)
We understand that embracing Value-Based Care can be a lot to take on, and at first, could potentially add to the Physician Task Load. This should not be the case – HCC coding can be learned in far superior ways than the tired conference room lecture (or zoom call). What if learning HCC coding was fun, easy, and actually gave clinicians an opportunity to engage with learning in a manner that added energy to their day, rather than depleting it?
On the Clinician Experience front, both our learning app and our integrated platform help ease the workload and improve the quality of life for clinicians. Ask us how?
Need to learn HCC coding, and don’t want to sit through another lecture? Click below to demo the DoctusTech app.
Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.
Live with Dr. Kazi – HCC Coding is Good For Patients
Live with Dr. Kazi is a new video series from Value-Based Care expert, Farshid Kazi, MD – Co-founder of DoctusTech, and passionate advocate for HCC coding and the Quadruple Aim. In our first episode, Dr. Kazi shares ways in which HCC coding is uniquely good for patients.
Watch the full interview here!
I’m Farshid Kazi, co-founder of DoctusTech and an internist by training with a focus on palliative care.
I’ve built my career on population health out in California.
I’m excited to help other physicians looking to take the journey and leap into value-based care.
Levi: On today’s episode of DoctusTech thought leadership, I want you to go in the weeds a little bit on the topic of HCC coding as it relates to value-based care – and how that is beneficial to patients. And I feel like this is one where I could just wind you up and send you running.
Dr. Kazi: Yeah. HCC coding such a dry topic, but I’m super passionate about it.
Only because it drives why I became a physician, right? And when we think about value based care, it’s such a big umbrella term. But in a very specific way, it’s really getting paid for providing better outcomes.
And when we were all training as physicians back in the eighties, nineties, and even early two thousands, it was about how many patients can you see a day, make sure you get them healthy and move them forward.
But now, value-based care is really paying us as docs to say, “Hey, here’s a subset of patients, take care of them. And if you can keep them healthy and out of the hospital, well, great. That’s profit in your back, your pocket. And if you can’t, then, you know, that’s risky.”
And so where HCC coding goes is, “Let me help appropriately document how sick my patient population is, so I get paid the proper amount!” And that’s not something any of us have been taught in med school. You’re taught how to diagnose a medical problem. You’re taught how to treat it, but when it comes to how to document—and be compliant—and actually show the severity of illness of your patient population, none of us have been taught to do that.
So it’s critical in this new shift.
Levi: Okay. So tell me as… let’s say, “I’m Levi. I have COPD. Why does this matter to me, doc?”
Dr. Kazi: Yeah, so if you are in a value-based care arrangement, your doctor—i.e. me—I care about what your outcomes are. I don’t want to see you only when you’re sick. I want to see you when you’re healthy and make sure you stay on that trajectory so that we keep you healthy.
And we prevent bad things from happening in a couple of years, when maybe you haven’t been taking your medication because it made you feel tired and you didn’t tell me that. And so therefore in three years, I find out you haven’t been taking your medication for three years!
So let’s focus on building that relationship and keeping you healthy before any a catastrophic event happens.
Levi: We use the phrase a lot, “aligning incentives,” and the fee-for-service model aligns incentives, financially around treating you when you’re sick and, and there’s actually a financial upside to sick people. How does this flip the paradigm for the patient?
Dr. Kazi: You can’t get around it, money being the primary driver on how a lot of businesses run, and there’s no hiding that medicine is still a business. And as long as that’s the case, physicians are paid and reimbursed only when I can bill for it.
I can’t bill to have Levi come in and talk to me because he’s having a tough time affording his medications or having a side effects from it. And I wouldn’t know that without bringing you in to have that conversation. I would see you only when something happened to you, you couldn’t breathe. You feel bad. I need to send you to the hospital!
But now in value-based care, I can bring Levi in whenever I want, because I know he’s just going to need a little bit more love and attention as we start to understand what the barriers to your care delivery are.
And so this new model allows me that flexibility to bring in the patients who I want, even if they’re healthy, because I think it’s going to have a change in our trajectory.
Levi: This is a little off topic, but remote patient monitoring and tele-health seem like they’re ways to make that even easier.
Dr. Kazi: That’s right. And there are a lot of companies that are emerging out here that are helping doctors do a number of different things in value-based care, tele-health, remote patient monitoring are all new emerging fields, because the penetration of value-based care reimbursements have gotten to about 30%.
We expect that to go even higher in the next couple of decades where the majority of people of Medicare age will be in some kind of value-based care arrangement.
Levi: Okay. So just to make sure I’m capturing this as a patient, you are financially incentivized to keep me healthier, because if I’m sick, it actually costs more money to take care of me.
If you maintain my health, it costs less money and your practice is more profitable. So you want me healthy probably as much or more than I do.
Dr. Kazi: Absolutely. And the hope is that it’s equal, right? So it’s a joint partnership there, and it allows me the flexibility to do so.
Levi: Now HCC coding: we talk a lot about recapture rate.
So if, if I have COPD, you have to diagnose that again next year in order to maintain that diagnosis. So you need some sort of a mechanism to do that. how does that serve me as the patient?
Dr. Kazi: So, if you forget the coding aspect to it, if you’re just thinking about it from a common sense perspective, you have COPD, you should probably be talking to your doctor about it at least once a year—if not more—saying, “How are things going?”
Any medical issues that you have that are chronic, that the government feels like they drive costs – we should be having a conversation. In fact, that’s a clinical decision that we should be making independent of the government. So as long as you and I are talking about it, it should be documented appropriately.
And that allows the government to say, “Yeah, Levi is at risk for clinical deterioration, but Dr. Kazi is doing the right things to care for him. And therefore here’s a pot of money that we want you to use to reinvest into, into Levi’s care!”
And that might be well visits. I might have a nurse call you just to check in with you. I might have just a, a best friend, who we call a care coordinator, check in with you and solve for loneliness. Make sure we look at your dietary constraints so that you’re not exacerbating some of your other diseases.
These are all ways that the government’s allowing me as a clinician and you as my partner, as a patient to think about where should we spend that money to keep you healthy and out of the hospital.
Need to learn HCC coding, and don’t want to sit through another lecture? Click below to demo the DoctusTech app.
Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.
RADV Audit White Paper – Planning Ahead For Strict HCC Compliance Protocols
Key Findings on From 400 RADV Audits, 2011-2021
What is a RADV Audit?
The Medicare Risk Adjustment Validation Program (RADV Audit) was created to identify and correct past improper payments to Medicare providers and implement procedures to help the Centers for Medicare & Medicaid Services (CMS), Medicare carriers, fiscal intermediaries, and Medicare Administrative Contractors (MACs) implement actions that will prevent future improper payments.
Simply put, it is a process whereby CMS validates payments and recoups over-payments.
How does a RADV Audit work?
CMS selects a statistically valid sample of members enrolled in an Affordable Care Act (ACA) compliant plan. Providers whose patients are selected for an audit receive requests and must provide copies of medical records.The audit seeks to verify that diagnosis codes, submitted on claims and reported to CMS, are accurate, properly documented, and coded with appropriate levels of specificity.
In accordance with the provisions of the Patient Protection and Affordable Care Act (PPACA) and its risk adjustment data validation standards, CMS then takes that statistical information and extrapolates from it the amount of overpayment that the health plan or billing entity is responsible for. In many cases this can range from several $100Ks to several $MMs.
Takeaway 1: Small errors return large chargebacks
Extrapolating from statistics based on errors yields significant sums.
In the three case studies referenced in the white paper, the overpayment ranged from 10% – 12% of total annual revenue. As a percentage of profit, that is a sizable number. While Einstein may have said that compound interest is the most powerful force on earth, we say that extrapolated overpayments are the most powerful force in ruining your year.
Takeaway 2: Some codes get misused more than others
These are the top three misused HCC codes from the audits data:
HCC
Description
HCCs added by unlinked chart reviews
Estimated payments from unlinked chart reviews
Percentage of unlinked payments
HCC108
Vascular Disease
105,607
$269,536,256
10%
HCC18
Diabetes w/ comp
74,221
$208,226,576
8%
HCC111
COPD
67,703
$189,101,725
7%
Takeaway 3: Provider behavior is the first thing to fix
While there are many ways to chase down diagnoses after the fact, the gold standard for HCC coding is at the point-of-care, right there with the patient. The opportunity for improvement in this stage has more to do with the tools that change behavior than the tools that chase data. Changing behavior is difficult, and the old-fashioned lecture approach to HCC learning is not likely to succeed.
Takeaway 4: Proper documentation fixes everything
Once the challenge of changing provider behavior has been tamed, the next beast lives inside the EMR. Whether you’re talking recapture rates or suspecting, there are significant financial risks in coding without proper documentation. Solutions that connect encounter data to HCC documentation to automate compliance are mission-critical for physician groups. These solutions will help groups provide top-quality care and protect them from negative RADV audits.
Takeaway 5: Without proper tools, documentation is daunting
At the risk of shameless self-promotion, we have enabled myriad providers with the tools to ensure the best possible outcome from a RADV audit. From capturing diagnoses at the point-of-care to ensuring documentation compliance — the DoctusTech family is ready for an audit. Our tools mean you are unlikely to be caught with your hand in the CMS cookie jar, and be put in the uncomfortable position of watching your revenue evaporate.
To learn more about how we prepare you for a RADV audit, help your providers improve HCC coding, and boost RAF accuracy by 30%, book some time with our HCC expert HERE.
The AAFP is a great first-stop for information on Risk Adjustment and HCC Diagnosis Coding. And although this article is a few years old (2018), their take on HCC Diagnosis Coding for Risk Adjustment is both unique and extremely helpful.
First, they lay out what it is and how it works. Then they tie it in with IDC-10 codes and HCC coding, to paint—with a broad brush—the full picture of what a practice will need to know, do and master to step into a risk adjustment payment model.
KEY POINTS
Mapping ICD-10 codes to Hierarchical Condition Category (HCC) codes determines the severity of illness.
Risk-adjustment factors heavily into new payment models.
Physicians should report any diagnosis codes associated with chronic conditions that affect treatment choices, not just the diagnosis codes that describe why a patient came in .
Physicians should comprehensively code chronic conditions at annual visits, as RAF (patient risk) scores reset every year.
HOW RISK ADJUSTMENT WORKS
First it may be helpful to briefly review the connection between coding, risk adjustment, and payment. Risk-adjustment models assign each patient a risk score based on demographics and health status. Demographic variables may include age, gender, dual Medicare/Medicaid eligibility, whether the patient lives at home or in an institution, and whether the patient has end-stage renal disease. Health status is based on the diagnosis codes submitted on inpatient, outpatient, and professional claims in a calendar year. Certain diagnosis codes map to disease groups (HCCs). Demographics and HCCs are weighted and used to calculate a risk-adjustment factor (RAF) score. – AAFP
The author then compiled a series of examples of HCC coding options, and how to determine which codes to use. Full list of examples here.
COMMON CONDITIONS AND HOW TO CODE THEM
Family physicians can increase the accuracy of risk-adjustment scoring by focusing on capturing diagnosis codes for the conditions they see frequently. Electronic health record (EHR) systems can help by identifying diagnosis codes that carry an HCC weight, but most do not. A related article in this issue includes a reference tool that physicians can use to keep HCC codes and RAF scoring in mind when selecting diagnosis codes.
Value-based Care Contracting is a key component to your VBC program. Fee-for-service contracts continue to be a challenge for VBC. The pandemic led to a drastic reduction in volumes that impacted FFS contracts revenue ($15B loss due to volume dips).
During the pandemic, organizations with value-based contracts were able to pivot operations to maintain revenue even when the volumes dropped. VBC payments will increase rapidly in the near future as hospitals and physician practices look to protect themselves against future downturns.
Value-based Care Contracting Image Credit: healthpolicy.usc.edu
Revcycle Intelligence (of Xtelligent Healthcare Media) shared an in-depth article highlighting how to succeed at value-based contracting. We share our takeaways from the article below.
Prior to engaging in contract negotiations:
Have a strong clinical leadership team to engage your physicians as their top priority (not 0.2 FTE).
Build a strong referral network that can be managed tightly with hospitals and specialists
Make a meaningful investment in changing FFS workflows to optimize patient care and care coordination. Tracking and accountability are key.
Build strong financial models. Do you have the resources that you need to manage those medical costs and administrative costs of that population that you might get?
Heading into contract negotiations:
Promote your organization’s quality metrics. Do you have longer clinic hours compared to your neighboring groups? Do you have better STARS/HEDIS scores? Are you leading in patient satisfaction scores?
Build an experienced team to handle payor contract negotiations. Every contract is unique, and the fine print matters. Most importantly, understand how your payor will attribute patients.
Don’t over-commit on what data you can collect and report. Prepare your IT infrastructure well ahead of time.
Make sure your payors will be good partners in promoting your group and helping you grow your patient base.
After the negotiation:
Growth is key because organizations need a panel of patients for contracts to work, and those patients cannot all be high-risk.
Keep close tabs on provider satisfaction, physician growth, and employer satisfaction with the care delivered.
Noticeable dips in quality performance may necessitate change and possibly another round of negotiation. Identify shortfalls early and frequently communicate with your payor partners.
Success begets success with payor contracts.
Read More: Value-Based Contracting 101: Preparing, Negotiating and Succeeding
You need a highly effective HCC Coding Program. If you’re a physician group engaging in value-based care arrangements: coding and documentation accuracy should be your top priorities. And inaction on your part will result in immediate loss of revenue and exposure to heavy audit penalties.
Whether you’re building a program from scratch or already have a program in place, the top five strategies for a successful program include:
Clinician Education — One-hour seminars or “codes of the month” emails don’t work.
Concurrent Chart Audits — This is more than checking boxes in the EMR to drag and drop chronic conditions into the progress note.
Point-of-care Clinical Guidance — Contrary to popular belief, we doctors don’t know everything! We make mistakes, and we don’t always have time.
Data Analytics — It’s painful and sometimes daunting, but it doesn’t have to be. Focus on a few critical points below to help drive an effective program.
Accountability — It’s a team effort. No single person should be held liable to be commended for the results.
HCC Coding Program Photo by RODNAE Productions from Pexels
Let’s dive deeper into your HCC Coding Program.
CLINICAL EDUCATION FOR YOUR HCC CODING PROGRAM:
Clinicians, on average, retain 15% of any educational seminar you send them to after residency. Even with 15% knowledge retention, there is a consistent regression to the mean after eight weeks. Out of sight, out mind!
No one size fits all, but we know the Socratic method of teaching, consistent education, and regular feedback result in sustained behavior change amongst clinicians.
Socratic method —
Stop teaching at doctors and start objectively testing their knowledge. Try clinical vignettes in small group settings. Problem-based learning is how most medical education is practiced today, and yet, coding education has not caught up. Customize training to your clinician skill sets and practice patterns to improve buy-in.
Consistent education —
Training is done once a quarter or via email will consistently fall flat. Clinicians have a lot going on, and to cement, any new information must be presented to them multiple times and in various ways. This doesn’t have to be time-consuming but does need to remain consistent.
Regular feedback —
We, clinicians, don’t like to be wrong and always strive to be better. So customized feedback on documentation accuracy and opportunities for improvement are critical. Moving away from clinic-based or team-based results. Make sure each of your clinicians knows their strengths and weakness as it compares to the group.
Clinicians, on average, retain 15% of any educational seminar you send them to.
CONCURRENT CHART AUDITS:
This will assist you to impact in 2 ways: A) Ensure compliant documentation B) Adjudicating any claims submitted.
A typical clinical documentation improvement program ensures correction of over-and-under coding before billing. Typically institutions “hold” a bill for two business days to make any corrections. During this period, the provider can be asked to clarify inaccurate documentation and adjudicate the superbill to ensure proper 1:1 matching with progress notes to billable codes. Much of this is currently handled at the payor level for smaller physician groups.
As you start to take on more risk as a physician practice, you’ll need a consistent strategy across all your payor contracts. While vendors are currently using a heavily manual process, emerging technology from DoctusTech will help you do this at the point of care with our A.I. This will drop your OpEx, decrease your risk during RAD-V audits, and give you a more accurate line of sight to your risk scores.
POINT OF CARE CLINICAL SUPPORT IN YOUR HCC CODING PROGRAM:
Doctors were not trained as coders, and coders were not trained as doctors. The basic premise of accurate documentation is and should be clinical. Clinicians need to take better histories, perform more accurate physical exams, and synthesize data to make clinical diagnoses. No coder or AI can replace and find these diagnoses as the data is inherently flawed with significant gaps.
DoctusTech can help doctors ask better questions, perform accurate exams, and present clinical guidelines to lets doctors practice medicine. This will inherently improve your RAF accuracy and create physician buy-in better than any Natural Language Processing or A.I. alone. Unfortunately, EMRs are limited by their data sets. They operate only off the information inputted, so if your PCP doesn’t have the complete clinical picture from your hospital systems and your specialists inputted into the EMR, the clinical decision support in your EMR will be lacking.
HCC Coding Program Photo by energepic.com from Pexels
DATA ANALYTICS:
No pilot would fly a plane without an operational dashboard, so why do we allow the same for such a critical part of our value-based care business? No excuses, no delays. The ability to aggregate data from outside your EMR, deliver individual physician report cards on HCC documentation, and having visibility to patient annual wellness visits (AWVs) for everyone on the team is critical. If your team doesn’t have bandwidth, vendor it out. Time is critical, and the ROI is clear.
Remember, if the data is not easy to fetch and easy to understand, no one will use it. This does not need to be an expensive endeavor. Make sure you have visibility to the following data points by an individual physician.
Patient panel
Suspect vs. chronic diagnosis by patient
Complete vs. incomplete AWVs
% conditions addressed by a physician at each visit
Documentation accuracy
ACCOUNTABILITY:
Whether you plan to use a stick or a carrot approach to accurate documentation, the strategy needs to be intentional and meaningful. The entire team plays a role in an effective program, and accordingly, the strategies you deploy should touch each individual team member in a meaningful way. Rewards do not need to be financial, and the motivation here is it drives better clinical care. The emphasis in the following areas are compliant and effective:
Documentation accuracy
% AWVs scheduled
Regular engagement with any coding tools
DoctusTech’s proprietary A.I. can be embedded into your EMR or on your mobile phone to help you complete steps 1,2,3,4 very effectively. All you have to do is be ready to hold your team accountable.
What is HCC coding? HCC stands for hierarchical condition category. It is a risk-adjustment coding model exclusively designed for estimating future healthcare costs for patients. The process of HCCs medical coding started in 2004, but it recently gained popularity due to payment models shifting from fee-for-service (FFS) to value-based care (VBC) arrangements.
Fig 1. Out of 70,000+ ICD10 codes, approximately 9,500 ICD10s map to a hierarchical condition category. Each HCC ICD10 is subsequently bucketed into 86 individual “condition categories.”
Fig 2. Each of the 9,500 HCC codes are put into one of 86 condition categories. Each condition category carries a specific RAF. No matter how many ICD10 conditions a patient has in the same category, they will only be assigned the RAF score one time.
Medicare assigns a risk score known as a risk adjustment factor (RAF) to each of the 86 individual condition categories. RAF scores of patient populations are subsequently used by Medicare and other payors to predict the cost of care, which influences reimbursements.
For the remainder of this article, we will explore the rationale behind HCC coding and why all providers (even those NOT in a value-based care arrangement) should care.
Why should doctors care about HCC coding?
HCC coding is the cornerstone of most value-based care arrangements. Today, “value-based care” is used synonymously with Medicare Advantage, but in the near future, we believe all forms of reimbursement will be tied to some VBC arrangement.
HCC coding falls under the broader term of risk adjustment (RA) models where patient care is paid based on a prospective payment model. Specially designed RA models are used to determine risk scores for patients. In the Medicare Advantage world, these models use the demographics and HCC diagnoses of the patient to assign a risk score known as an RAF. The assumption is the sicker the patient, the higher the RAF, the more dollars it will take to care for this patient during any given year. Therefore the RAF score of any patient population will determine the prospective payment Medicare disburses.
This prospective payment model based on RAF does 2 things:
1. Aligns physician incentives. Currently, clinicians make money from taking care of sick patients. The sicker the patient, the more visits, tests, surgeries they have to do, and the more they are reimbursed. In this model, clinicians are incentivized to keep patients healthy and therefore require LESS tests and surgeries.
2. Spurs clinical innovation the right way. Right now, pharmaceuticals and medical hardware companies are all trying to find ways to treat diseases. The newer the drug or medical device, the more revenue they make. In this model, healthcare groups are incentivized to find new ways of preventing the disease progression from ever needing the latest drug or newest medical surgery equipment.
As Medicare and payers alike are starting to take notice of #1 and #2 above, the market is now trending towards building in value-based care drivers to all types of patients outside of Medicare Advantage. It’s unlikely a brand new risk model will be born for commercial patients. Therefore, all physicians will need to understand the risk adjustment models and the implications of documentation accuracy for reimbursement.
Conclusion
HCC coding is here to stay and will only grow in the years to come. While the market has heavily leveraged medical coders or third party vendors to do much of the lift thus far, V2 of Value-based Care will require all clinicians to understand and participate in it for every patient visit.
HCC coding’s importance is less about the impact on revenue and more about the shift towards VBC models, which have consistently shown better clinical outcomes at lower costs. In our next 2 posts, we will dive deeper into the financial implications of HCC coding, HCC coding tools, and the clinical outcomes associated with VBC in 2021.
