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How to Achieve Accurate HCC Coding with AI
December 16, 2024
If you’re reading this, you’re likely aware that accurate HCC coding is critical within value-based care (VBC) models. Yet, clinicians often face challenges with complex workflows that make documentation difficult.
Fortunately, emerging technologies like Artificial Intelligence (AI) offer innovative solutions to the... Read more
8 Common HCC Coding Errors and How to Avoid Them
November 20, 2024
When considering a patient’s chart, every detail matters. It’s not just about the diagnosis, it’s the whole picture – missing something could affect the quality of care your patient receives. By now, it’s clear to most HCPs that Read more

HCC V28: How to Prepare
July 18, 2024
Introduction
By 2025, the transition from HCC V24 to V28 will be complete. CMS has already begun a phased transition to the new model, but as we move into Q3, time is running out to prepare for 100% adoption. So what can organizations do to be ready for HCC V28? How can they remai... Read more
How to Prepare for a RADV Audit
July 7, 2024
Research compliance in the CMS risk-adjustment model and you might come away with more questions than answers. There are few rigid guidelines or ... Read more

How VBC delivers on the quadruple aim
June 11, 2024
When we talk about optimizing health system performance in the value-based care (VBC) model, it’s common to refer to the Read more

Why does accurate HCC coding matter?
May 7, 2024
Clinicians and other medical staff find it hard to care about HCC coding. Here’s why they should.
Selling clinicians on the value-based care (VBC) model should be straightforward. In theory, it promises more time with patien... Read more

Exploring blended payments
April 30, 2024
We asked VBC thought leaders to share their experiences of fee-for-service and value-based reimbursement models.Â
While value-based payment models are on the rise in the U.S, primary care practices still receive the majority of their pay... Read more

7 Strategies to improve HCC coding and risk adjustment accuracy
November 2, 2023
Healthcare is a dynamic and complex industry, constantly evolving to provide the best possible care to patients. In this ever-changing landscape, accurate Hierarchical Condition Category (HCC) coding and risk adjustment<... Read more

What is the CMS HCC Risk Adjustment Model?
April 28, 2023
The CMS, or Centers for Medicare & Medicaid Services, developed the HCC Risk Adjustment Model to determine Medicare Advantage (MA) plan payments, based on the expected healthcare costs of plan enrolees. HCC stands for Hierarchic... Read more

Why is HCC coding important for medical practices?
April 13, 2023
'HCC coding' is shorthand for the Hierarchical Condition Category (HCC) coding system used to identify and classify medical conditions for the purpose of risk adjustment. ThisRead more

How to improve HCC documentation and reduce risk
March 23, 2023
Healthcare providers and payers use the HCC coding system to identify the seriousness and severity of a patient’s medical condition. The main purpose of coding is to ensure that a patient receives good medical... Read more

How to Improve Risk Adjustment Factor Score Accuracy
February 22, 2023
Medicare risk adjustment factor score accuracy is an important measure of the quality of care provided by healthcare providers. By understanding and applying proven strategies to improve RAF score accuracy, healthcare organizations can demonstrate their commitment to quality care and improve overall patient outcomes. In this article, ... Read more

Overcoming the costs of bad HCC coding education
January 20, 2023
HCC (Hierarchical condition category) coding is a complex and ever-changing field, and training clinicians in the traditional seminar format can cause significant pain points for healthcare providers and administrators. Here are just a few examples of the pain points that result from HCC coding education seminars: Inaccurate or incomplete information: Traditional seminars often... Read more

Risk, Revenue & Care: How HCC coding and RAF impact Value-Based Care Revenue and Patient Outcomes
January 20, 2023
The basics of RAF and how it is calculated.
Total HCCs for a single patient equal RAF score Every VBC patient has a Risk Adjustment Factor (RAF) score, and the score follows the patient. The more medically complex diagnoses render a higher RAF score. The higher the score, the more resources required to care for that patient; therefore, Medicare pays more to care for... Read more
What to expect during a CMS audit?
January 20, 2023
A CMS Medicare Advantage audit is a process used by the Centers for Medicare and Medicaid Services (CMS) to ensure that Medicare Advantage (MA) plans, also known as Medicare Part C, are complying with regulations and standards set by the CMS. The process includes several stages, including notification of the audit, preparation, on-site review, audit findings, and potential repayment or appeals. ... Read more

The Risks of Inaccurate HCC Coding: Why it Matters for Your Practice
January 12, 2023
As a healthcare provider, it's essential to understand the importance of accurate HCC (Hierarchical Condition Category) coding. HCC codes are used to classify patient conditions, which determines Medicare Advantage payments. Inaccurate HCC coding can have serious consequences for both your practice and your patients. Inaccurate HCC Coding Impac... Read more

Value-Based Care Revenue and Outcomes: Impact of HCC Coding and RAF
January 12, 2023
Diagnosing for risk in VBC is the unsung hero fixing healthcare behind the scenes. In this blog, we dig into diagnosing for medical complexity & documenting with ICD-10 codes.Â
Diagnosing for medical complexity
Physician diagnoses patients with all medical cond... Read more
New HCC Coding Cheat Sheet for 2022
January 12, 2023

How to wean your clinicians off HCC coding cheat sheets
January 11, 2023
As a healthcare provider, you know the importance of accurately and consistently documenting diagnoses, but not just to align revenue - there is a far greater reason for specific, accurate HCC coding: patient care. One thing that is often overlooked when calculating RAF scores is the simple fact that Risk Adjustment Factor is the simplest way to track a patient’s ... Read more

How HCC coding and RAF impact Value-Based Care Revenue
January 11, 2023
The relationship between medical complexity, documentation, risk, innovation, and revenue is actually far more simple than it sounds.
We are often asked very broad questions about how all of the moving pieces of VBC work together. How does highly specific and accurate diagnosing with HCC code... Read more
So Your Team Downloaded Our Cheat Sheet…
November 29, 2022
We get it, HCC coding is hard: choosing the right HCC is nuanced, and can seem subjective. But when you see a patient, you are probably not reaching for a cheat sheet on how to diagnose this patient, right? How is it that HCC coding sent you searching for a cheat sheet? &n... Read more

VBC Industry Insights From HCP-LAN’s Annual Report
November 22, 2022
Values-based healthcare reimbursement has been adopted more quickly in some healthcare sectors than in others. According to the LAN's latest APM Measurement report, 40.9% of US healthcare payments—representing over 238 million Americans and more than 80% of the covered population—were generated through value-ba... Read more

Bolus of Vintage CMS Audits Reveal Millions in MA Overcharges - KHN
November 21, 2022
Fred Schulte, Kaiser Health News and Holly Hacker Republished with permission
Newly released federal audits reveal widespread overcharge... Read more
How Hospitals Can Tackle Surges With Value-Based Care
November 14, 2022
With the flu season ramping at unprecedented rates, and a new surge of RSV coming when COVID-19 numbers are rising again, the topic of a healthcare surge emergency is back in the headlines. What the New York Times is calling a “Tripledemic†is threatening to overwhelm providers and hospitals yet again. During the peak of the pandemic, hospitals experienced a sur... Read more

HCC Codes Most Targeted by DOJ and Strategies to Remain Compliant
November 8, 2022
Audits are no longer just for large payors, provider groups are feeling the pressure of rising compliance audits, and the playing field is complicated to negotiate. Some of this may seem unfair, but with the cost of medical fraud on the rise, the DOJ, CMS, OIG, HMS and all the other initials are not going to let up any time soon, if ever. Read more

What Is HCC Coding?
October 31, 2022
Back in 2004, CMS introduced HCC coding as a tool to help estimate Medicare costs. Today, HCC coding us used across Medicare Advantage plans, the Medicare Shared Savings Program, Medicaid, and private health plans - all deploying a variation of the risk adjustment model in order to quantify the upcoming cost of care for their member population, and as a mechanism of... Read more

DOJ Files New Medicare Abuse Lawsuit Against Cigna
October 20, 2022
DOJ Audits And How DoctusTech Helps
The Department of Justice has filed a new lawsuit against Cigna for overcharging the federal government by purposefully inflating how sick its Medicare Advantage members are. Read more
Nearly 60 percent of health systems are looking to move into risk-based Medicare Advantage programmes in the coming year, according to the Healthcare Financial Management Association (HFMA) executive survey for Guidehouse Health Insights. This is a 14 percent increase from the June 2019 Guidehouse/HFMA analysis, Guidehouse said. Read more

DoctusTech Helps: Change Clinician Behaviour
October 4, 2022
According to the American Journal of Managed Care (AJMC), the least effective method for continuing medical education (CME) for clinicians is distributing printed materials: emails, PDFs, flyers, email blasts, and so on. Many medical professionals believe that clinician education should be concerned with encouraging continuous development rather than simply raising ... Read more

DoctusTech Helps Value Based Care
October 4, 2022
Value-Based Care is a natural movement toward the benefit of the patient with a reduction in costs by aligning all incentives in the right direction. And as providers make the shift, patients will be encouraged both by the motive behind the transition as well as the improvement in their overall health and the reduction in the costs of their care. Truly, Value-Based ... Read more

CVS Health to purchase Signify Health for $8B
September 26, 2022
In an effort to strengthen its presence in the healthcare technology sector, CVS Health has announced plans to acquire Signify Health for $8 billion. CVS will be acquiring Signify from private equity firm TPG and other Signify shareholders. As a result of this acquisition, CVS will now have access to Signify’s enterprise-grade software solutions for clinical asses... Read more

DoctusTech Helps: Decrease Clinician Workload
September 12, 2022
In December of 2021, the Mayo Clinic published an alarming report: ⅓ of physicians surveyed intended to reduce their work hours - that represents 336,000 doctors. While—and I hope you are sitting down—1 in 5 physicians intended to leave their practice altogether - 20%, or 204,000. The cause? Burnout. Burnout from workload, COVID-19–related anxiety/depression, and fear of contracting ... Read more

DoctusTech Helps: Deploy HCC coding education across your organization
September 8, 2022
HCC coding accurately estimates future healthcare costs while improving patient care. But like any other tool, it’s only effective if the people who use it mas... Read more

DOJ Joins Cigna Medicare Advantage Fraud Case
August 31, 2022
DOJ jumps into yet another False Claims Act lawsuit, this time regarding the Cigna Medicare Advantage Fraud Case. The Department of Justice has joined a False Claims Act lawsuit against Cigna Corp. that alleges the health insurance provider exaggerated the illnesses of its Medicare members in order to receive higher payouts from the federal government. &... Read more

DoctusTech Helps: Increase RAF Accuracy
August 23, 2022
“I don’t care if the RAF goes up or down, I only care if it’s accurate.†Dr. Farshid Kazi, Co-Founder, DoctusTech If an organization is caught over-coding, up-coing, diagnosing conditions that either do not exist or are not supported in the chart, the cost of these ... Read more

Amazon Announces Plans to Buy OneMedical
August 12, 2022
Amazon has announced plans to buy OneMedical for $3B. OneMedical is a brick and mortar plus digital healthcare marketplace that operates in several major U.S. markets. The acquisition is Amazon’s latest move in the healthcare sector, and analysts say it could be a sign of bigger things to come. This is not Amazon’s first foray into the healthcare market, but aft... Read more

DoctusTech Helps Clinicians Learn HCC Coding
August 5, 2022
DoctusTech helps clinicians learn HCC coding through clinical vignettes in an app that is fun and engaging. Diagnosing with the appropriate HCC code is a critical skill for modern clinicians who care for patients in a value-based care arrangement. You cannot treat what you do not accurately diagnose, and you cannot afford to treat what you do not appropriately code.... Read more

Everything You Need To Know About HCC Coding Training
August 2, 2022
Why is HCC coding training important? Without proper coding, it is impossible to diagnose accurately, treat effectively, document those diagnoses, or achieve revenue goals. Coding training will help you master the skills you need to properly code patient records, so investing in HCC coding training might be the right move for you! Read on to learn more about HCC cod... Read more

Risk adjustment coding is a vital part of any managed care organization. It helps to ensure that patients are appropriately diagnosed and documented accurately according to risk level, which in turn allows the organization to receive appropriate capitated payments to provide all the care needed to reduce avoidable hospitalizations and achieve maximum health. And reg... Read more

Value-Based Care is a game-changing advancements for patients and the providers who care for them. Value-based care is revolutionizing the healthcare industry and aligning incentives more and more each year. The concept of pay-for-performance, patient-centered care, and outcome measures have all been developed with the intention of providing more value to patients... Read more

HCC Coding And RAF are vital to modern healthcare, and we've recently received some incredible client data we'd very much like to share. And we all know the perils of sharing a win that deals with customer data, which is in turn patient data. And by “perils,†what we really mean is impossibility. Sometimes, the news is so good that it’s impossible not to share... Read more

4 HCC Coding Education Strategies for Physicians
July 11, 2022
HCC coding education is a fast growing need for physicians. To meet the demands of today’s fast-paced and dynamic healthcare environment, many are now accelerating their transformation from a hospital-centered fee-for-service model to a more patient-centered model, and Value-Based Care is at the forefront of this change. The increased HCC coding knowledge requires... Read more

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. Read more

Revenue cycle management (RCM) is a hot topic this year. Monitoring, analyzing and improving the efficiency of your organization’s revenue processes is top of mind for leaders across many healthcare organizations. And you’ are probably still reading because you know that improving your organization’s revenue processes is essential to its success. But are you d... Read more

4 HCC Coding Challenges All Clinicians Face
July 3, 2022
As the U.S healthcare system transitions towards value-based payment models, independent clinicians and physician groups continue to face HCC coding challenges that not only impact their bottom-line, but patient care as well. On top of all this, the pandemic has added a significant burden to the already stretched clinician workload. Here are 4 key HCC coding challenges clinicians are ... Read more

SCOTUS Secures Medicare Advantage Overpayment Rule
June 30, 2022
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.
Read more

HCC Coding and Physician Burnout
June 14, 2022
RaDonda Vaught was just sentenced to three years of supervised probation. The former Vanderbilt University Medical Center nurse was found guilty of negligent homicide and gross neglect of an impaired adult in the death of a patient, because she administered Read more

Implementing Value-Based Care is essential for today's physician. Value-based care is a system of payment and reimbursement that rewards healthcare providers for delivering high-quality, cost-effective care to patients. There are two ways to improve the value of care: improving the quality of care (fewer complications, less re-hospitalization, shorter length of stay... Read more

A Quick HCC Coding Knowledge Hack
May 19, 2022
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, ... Read more

Healthcare Industry Shift Toward VBC
May 13, 2022
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 Indu... Read more

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 ... Read more

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... Read more

How To Change Physician Behavior - from AJMC
April 29, 2022
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... Read more

6 Recent HHS OIG Medicare Advantage Compliance Audits
April 27, 2022
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 specif... Read more

DOJ Healthcare Audits Charged $5 Billion In 2021
April 25, 2022
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... Read more
HCC Coding Education For Family Physicians - AAFP
April 20, 2022
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... Read more

Educating Doctors on HCC Coding
April 18, 2022
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. Read more

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 Beneficiar... Read more

Value-Based Care: It's All About The Money
April 14, 2022
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’ donâ€... Read more

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. Secr... Read more

We recently ran a poll asking how doctors preferred to learn about HCC documentation training tools and resources, and 50% selected “Peer Recommendations.†Fortunately, doctors just like you are using and loving our platform, and eager to share their experiences. We’ve broken their testimonials into three categories: Ease of use, Depth of learning, Accuracy,... Read more

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 do... Read more

VBC Strategies for 2022: What to STOP, START and CONTINUE?
January 7, 2022
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 tr... Read more

Risk Adjustment Coding in MSSP // ACOs
October 22, 2021
CMS released its final Medicare Shared Savings Program rule, called “Pathways for Success†for ACOs. The new rule is designed to help establish a path toward risk, with a heavy focus on Risk Adjustment Coding. CMS = Centers for Medicare & Medicaid Services || Read more

DOJ vs Sutter Health - Live with Dr. Kazi
October 5, 2021

Sutter Health Settles with DOJ for $90 Million
September 14, 2021
Sutter Health Settles with the DOJ is not a phrase we thought we'd ever see on our blog. We recently published a white paper on RADV audits and the importance of strict HCC compliance. A few weeks late... Read more

HCC Coding is Good For the Country - Live with Dr. Kazi
September 8, 2021

HCC Coding is Good For Providers - Live with Dr. Kazi
September 1, 2021
Read more

Physician Burnout - Study Finds Work-Load Root Cause
August 26, 2021
Battling Physician Burnout is a top priority. One pillar of The Quadruple Aim is to Improve the clinician experience. Even before the COVID crisis, Physician Burnout has been a growing concern. And after 18 months of increased workload and stress, the problem is getting worse, not better. The Joint Commission Journal on Quality and... Read more

HCC Coding is Good For Patients - Live with Dr. Kazi
August 24, 2021
Live with Dr. Kazi - HCC Coding is Good For Patients

RADV Audit White Paper - Top 5 Takeaways
August 16, 2021
RADV Audit White Paper - Planning Ahead For Strict HCC Compliance Protocols
Key Findings on  From 400 RADV Audits, 2011-2021Â
What is a RADV Audit?
The Medicare Risk Adjustment Validation PRead more
Diagnosis Coding For Risk Adjustment - Are You Ready (AAFP)
August 3, 2021
The AAFP is a great first-stop for information on Risk Adjustment and HCC Diagnosis Coding. And although this article is a few years old (2018), their take on HCC Diagnosis Coding for Risk Adjustment is both unique and extremely helpful. First, they lay out what it is and how it works. Then they tie it in with IDC-10 codes and HCC coding, to paint—with a broad brush—the full picture of what... Read more

Value-based Care Contracting 101
June 21, 2021
Value-based Care Contracting is a key component to your VBC program. Fee-for-service contracts continue to be a challenge for VBC. The pandemic led to a drastic reduction in volumes that impacted FFS contracts revenue ($15B loss due to volume dips). During the pandemic, organizations with value-based contracts were able to p... Read more

You need a highly effective HCC Coding Program. If you’re a physician group engaging in value-based care arrangements: coding and documentation accuracy should be your top priorities. And inaction on your part will result in immediate loss of revenue and exposure to heavy audit penalties. Whether you’re building a program from scratch or already have a program in place, the top five strateg... Read more

What is HCC Coding: Risk Adjustment Models in Value-Based Care
January 28, 2021
What is HCC coding? HCC stands for hierarchical condition category. It is a risk-adjustment coding model exclusively designed for estimating future healthcare costs for patients. The process of HCCs medical coding started in 2004, but it recently gained popularity due to payment models shifting from fee... Read more
