SCOTUS Secures Medicare Advantage Overpayment Rule

SCOTUS Upholds Medicare Advantage Overpayment Rule

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.

Unitedhealthcare Ins. Co. v. Becerra, 16 F.4th 867, (D.C. Cir. 2021)

 

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.

 

OIG: 13% of Medicare Advantage Prior Authorizations Inappropriately Denied

OIG 13 percent of Medicare Advantage Prior Authorizations Inappropriately Denied

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.

 

Learn more here [Book a demo].

A Quick HCC Coding Knowledge Hack

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

 

So we’ve built you one! Download the HCC Quick Guide 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.

 

Download the HCC Quick Guide Today!

Healthcare Industry Shift Toward VBC

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. 

 

Book some time with our expert team today, and start getting solutions that get your VBC contracts on track. 

The Market Is Moving Toward Full Risk Value-Based Care

Full Risk Value-Based Care

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.


Book a demo with DoctusTech’s Co-founder today!

The Rise of Risk: Value-Based Care Payments Increasing Year Over Year

The Rise of Risk - HCPLAN APM alternative payment model Framework- Value-Based Care Payments Increasing

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 APM alternative payment model Framework- Value-Based Care Payments Increasing

 

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. 

FFS vs Quality vs VBC Chart - Value-Based Care Payments Increasing

 

 

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.

 

 

2015 HCPLAN Value-Based Care Payments Increasing 2016 HCPLAN Demonstrates Value-Based Care Payments Increasing
2017 HCPLAN APM Demonstrates Value-Based Care Payments Increasing 2018 HCPLAN APM Demonstrates Value-Based Care Payments Increasing
2019 HCPLAN APM Demonstrates Value-Based Care Payments Increasing 2020 HCPLAN APM Demonstrates Value-Based Care Payments Increasing

 

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!

 

How To Change Physician Behavior – from AJMC

How To Change Physician Behavior

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!.

 

Book a demo today.

6 Recent HHS OIG Medicare Advantage Compliance Audits

Medicare Advantage Compliance Audits HHS OIG

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 5 recent HHS OIC 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

 

Incorrectly Submitted Diagnosis Codes for Vascular Claudication: 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

 

Potentially Mis-keyed Diagnosis Codes: Anthem, Coventry, Healthfirst, Tufts, UPMC

 

 

Why OIG Does These Audits

 

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

  1. Some of the Diagnosis Codes That Humana Submitted to CMS
    Were Not Supported in the Medical Records
  2. 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.

Source: https://oig.hhs.gov/oas/reports/region7/71601165.pdf

 

HHS OIC Medicare Advantage compliance audit #2

UPMC Health Plan, Inc. –  $6.4 million

 

How OIG Did This Audit

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

  1. Incorrectly Submitted Diagnosis Codes for Acute Stroke
  2. Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
  3. Incorrectly Submitted Diagnosis Codes for Acute Stroke and Acute Heart Attack Combination
  4. Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
  5. Incorrectly Submitted Diagnosis Codes for Embolism
  6. Incorrectly Submitted Diagnosis Codes for Vascular Claudication
  7. Incorrectly Submitted Diagnosis Codes for Lung Cancer
  8. Incorrectly Submitted Diagnosis Codes for Breast Cancer
  9. Incorrectly Submitted Diagnosis Codes for Colon Cancer
  10. 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.

Source: https://oig.hhs.gov/oas/reports/region7/71901188.pdf

 

HHS OIC Medicare Advantage compliance audit #3

Healthfirst Health Plan, Inc. – ​​$5.2 million

 

How OIG Did This Audit

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

  1. Incorrectly Submitted Diagnosis Codes for Acute Stroke
  2. Incorrectly Submitted Diagnosis Codes for Acute Stroke and Acute Heart Attack Combination
  3. Incorrectly Submitted Diagnosis Codes for Embolism
  4. Incorrectly Submitted Diagnosis Codes for Vascular Claudication
  5. Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
  6. 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.

Source: https://oig.hhs.gov/oas/reports/region2/21801029.pdf

 

HHS OIC Medicare Advantage compliance audit #4

Tufts Health Plan –  $3.7 million

 

How OIG Did This Audit

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

  1. Incorrectly Submitted Diagnosis Codes for Acute Stroke
  2. Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
  3. Incorrectly Submitted Diagnosis Codes for Acute Stroke and Acute Heart Attack Combination
  4. Incorrectly Submitted Diagnosis Codes for Embolism
  5. Incorrectly Submitted Diagnosis Codes for Vascular Claudication
  6. Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
  7. 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.

Source: https://oig.hhs.gov/oas/reports/region1/11900500.pdf

 

HHS OIC Medicare Advantage compliance audit #5

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

  1. Incorrectly Submitted Diagnosis Codes for Acute Stroke
  2. Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
  3. Incorrectly Submitted Diagnosis Codes for Acute Stroke and
    Acute Heart Attack Combination
  4. Incorrectly Submitted Diagnosis Codes for Embolism
  5. Incorrectly Submitted Diagnosis Codes for Vascular Claudication
  6. Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
  7. 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.

Source: https://oig.hhs.gov/oas/reports/region7/71901187.pdf

 

HHS OIC Medicare Advantage compliance audit #6

Coventry Health Care of Missouri, Inc. – $548,852

 

How OIG Did This Audit

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

  1. Incorrectly Submitted Diagnosis Codes for Acute Stroke
  2. Incorrectly Submitted Diagnosis Codes for Acute Heart Attack
  3. Incorrectly Submitted Diagnosis Codes for Embolism
  4. Incorrectly Submitted Diagnosis Codes for Vascular Claudication
  5. Incorrectly Submitted Diagnosis Codes for Major Depressive Disorder
  6. 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.

Source: https://oig.hhs.gov/oas/reports/region7/71701173.pdf

 

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DOJ Charged $5 Billion To Healthcare In 2021

Excerpts, notes and quotes from the DOJ 2021 Fiscal Year Report

Justice Department’s False Claims Act Settlements and Judgments Against Healthcare Exceed $5 Billion in Fiscal Year 2021

DOJ Healthcare Audits Charged $5 Billion In 2021

Justice Department’s False Claims Act Settlements and Judgments Against Healthcare Exceed $5 Billion in Fiscal Year 2021

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.

 

Other areas of Settlements and Judgments:

  • Unnecessary Medical Services
  • Combating the Opioid Epidemic
  • ​​Unlawful Kickbacks
  • Procurement Fraud
  • COVID-Related Fraud
  • Holding Individuals Accountable
  • Cybersecurity Initiative
  • Recoveries in Whistleblower Suits

 

Justice Department’s False Claims Act Settlements and Judgments Against Healthcare Exceed $5 Billion in Fiscal Year 2021

Source: DOJ

HCC Coding Education For Family Physicians – AAFP

HCC Coding Education For Family Physicians.png

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. 

 

What is the M.E.A.T Criteria in HCC coding?

  • Monitor – signs, symptoms, disease progression, disease regression 
  • Evaluate – test results, medication effectiveness, response to treatment 
  • Assess – ordering tests, discussion, review records, counseling 
  • Treat – medications, therapies, other modalities

 

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.

Educating Doctors on HCC Coding

Educating doctors on hcc coding made easy in the DoctusTech app

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:

 

    1. 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.
    2. 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.
    3. 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.
    4. 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.
    5. 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.

     

    Try the HCC Coding Education App that is changing behavior and paving the way for your successful VBC program.

  1. Demo the app today.

VBC: Full Risk Shows Lower Preventable Hospitalizations of MA Beneficiaries, Study

value-based care full risk model shows lower preventable hospitalizations in recent study_

Excerpts from a study.

 

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)

 

Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries - gondi_2022

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?

Value-Based Care: It’s All About The Money

value-based care it's all about the money

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.

 

Value-Based-Care-is-All-About-The-Money-DoctusTech-VBC-HCPLAN-Annual-Report-2017-2021

 

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. 

 

Healthier patients, happier doctors, silver bullet.

 

 

 

 

Want your team to master HCC coding faster with better long-term retention, boosting RAF accuracy and earning 25 hours of accredited CME?

Ask us how.

HHS Secretary Xavier Becerra Addresses Upcoding in Medicare Advantage, State of the Department Press Conference

HHS secretary Xavier Bacerra on overcoding in medicare advantage

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
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
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.

 

View just the Medicare Advantage portion here: https://youtu.be/WJUf4akou_Y?t=3538

View the full address here: https://youtu.be/WJUf4akou_Y

ACO REACH Model Replaces GDCP (DCE) Model – But What Really Changed?

ACO REACH DCE CMS

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 Equitythe 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.

Access the full report below.

 

 

VBC Strategies for 2022: What to STOP, START and CONTINUE doing in the new year

 

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:

 




 

Click below to see how we solve for this at DoctusTech .

 

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.

 

Demo the tools that make HCC coding easy

ACOs & The Importance of Risk Adjustment Coding in MSSP

ACOs Risk adjustment coding in medicare shared savings program HCC MSSP

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.

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

Basic & Enhanced Tracks
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 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…..

 

Click below to see how we solve for this at DoctusTech .

 

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.

 

Demo the tools that make HCC coding easy

Live with Dr. Kazi – Discussing the DOJ vs Sutter Health, $90MM Settlement

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 third episode, Dr. Kazi shares ways in which HCC coding is good for the country.

 

 

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 that case? 

 

 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.

 

Demo the tools that make HCC coding easy

 

Sutter Health Settles with DOJ for $90 Million

DOJ Sutter Health

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. 

 

 

Resources:

 

Read the DOJ’s full statement HERE.  

 

Access our HCC Quick Start Guide HERE.

 

Access the full white paper HERE.

Planning Ahead For Strict HCC Compliance Protocols
Key Findings From 400 RADV Audits, 2011-2021

 

 

Live with Dr. Kazi – How HCC Coding is Good For the Country

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 third episode, Dr. Kazi shares ways in which HCC coding is good for the country.

 

 

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: 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.

 

Demo the tools that make HCC coding easy

 

Live with Dr. Kazi – How HCC Coding is Good For Providers

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 second episode, Dr. Kazi shares ways in which HCC coding is uniquely good for doctors.

 

 

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: 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.

 

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.

 

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.

 

Demo the tools that make HCC coding easy

 

Work Load Root Cause of Physician Burnout, Study Finds

 

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?

 

 

Read the study here: Physician Task Load and the Risk of Burnout Among US Physicians in a National Survey

 

 

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.

Demo the tools that make HCC coding easy

 

Live with Dr. Kazi – How 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.

 

Demo the tools that make HCC coding easy