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What is the typical insurer audit process for physician groups?

Audit conversations get messy fast, mostly because the “rules” aren’t public.

 

Each payer has its own criteria, and few are transparent about what triggers a review, what counts as “supported,” or how findings are weighed. That leaves most physician groups navigating gray zones, trying to stay compliant without a clear map.

 

In this article, we’ll break down what typically happens during an insurer audit, how these reviews are structured, what triggers them, and how to reduce exposure without pretending anyone has all the answers.

 

To make sense of the process, it helps to first clarify what we’re actually talking about when we say “insurer audit.” 

 

What we mean by “insurer audit”

 

This term often gets used loosely, but it usually covers two very different activities, and understanding that distinction is key before diving into how these audits really work.

 

1. Front-door approval checks

 

As diagnoses and encounters flow to the plan, the payer may flag items they won’t accept or forward to Medicare.

Think of this as a gatekeeper function, sometimes automated, sometimes human-assisted. If something looks off, it’s bounced back.


2. Retrospective or targeted reviews run by the plan

 

Here, plans look backward. They review historical charts to identify documentation gaps and help providers correct processes going forward. These reviews are typically protective in intent: “Fix this now so neither of us gets in trouble later.”

 

Understanding the distinction between preventive gatekeeping and retrospective audits is key because each one requires a different strategy for documentation and follow-up.

 

How insurer audits usually work

 

At their core, insurer audits are designed to confirm that submitted claims reflect accurate, compliant, and medically necessary care. The process often starts with data analytics. Insurers use algorithms to identify outliers such as unusually high risk scores, frequent upcoding, or billing patterns that deviate from peers.

 

Once flagged, the insurer typically issues a records request, asking the provider group to submit documentation that supports the diagnoses and services billed.The insurer reviews progress notes, test results, and treatment plans to confirm coding accuracy, compliance, and medical necessity. The findings can result in:

 

    • Validation, confirming that claims were appropriate.
    • Adjustment, which may reduce payment or trigger repayment.
    • Education, where providers are offered guidance on documentation gaps.

 

If systemic issues or potential fraud are suspected, the review may escalate into a full audit or referral to external entities such as the Office of Inspector General (OIG) or the Centers for Medicare & Medicaid Services (CMS).

 

What triggers reviews or audits

 

Not all audits are random. Common triggers include:

 

    • Whistleblowing or complaints
    • Rapid growth or sudden revenue jumps
    • Random selection (especially at the CMS level)
    • Payer gatekeeping patterns (frequent rejects can prompt deeper looks)

 

Understanding these triggers helps organizations spot early warning signs before the notice arrives.

 

The pros: why audits exist

 

Audits aren’t purely punitive; they exist to protect data and the credibility of value-based care.

 

    • Improved Accuracy and Integrity
      Audits reinforce proper coding and documentation standards, ensuring that claims reflect the actual care delivered. For value-based organizations, this facilitates the development of more accurate patient risk profiles.
    • Opportunities for Education
      Some audits include provider feedback, revealing areas where documentation practices are lacking. These findings can lead to targeted retraining, improved compliance, and better alignment with payer expectations.
    • Protection for Payers and Providers
      Regular reviews help prevent fraudulent or accidental overpayments that could otherwise lead to larger liabilities down the line.

 

The cons: why audits are so challenging

 

Despite their purpose, audits often strain clinical and administrative teams.

 

    • Administrative Burden
      Reviewing hundreds of charts consumes valuable staff time, diverting resources from patient care and operations.

 

    • Inconsistent Criteria
       Each insurer may apply different standards or interpretations of the same coding guidelines. What one payer deems compliant, another might dispute.

 

    • Delayed Revenue and Clawbacks
       Payment holds, recoupments, or demand letters can disrupt cash flow. Even when the group ultimately prevails, the process may take months to resolve.

 

Audits balance accountability with ambiguity, and it’s in that gray space that most tension lives.

 

The Gray Areas (a.k.a. Why Reasonable People Disagree)

 

Four common gray areas explain most disagreements.

 

1) “Supported” vs. “Appropriate” (the biggest gap)

 

    • Coder lens: “Is there any evidence this diagnosis belongs here?” If the note cites a lab, study, or a brief assessment, the code is “supported.”
    • Auditor/clinician lens: “Does this diagnosis make clinical sense right now?” Example: coding acute stroke off an old imaging result. A coder might pass it; an auditor may call it non-compliant for the current encounter (and for risk purposes).
    • Why it matters: Minimal, one-letter MEAT tends to “support” codes without proving clinical relevance and active management, precisely what auditors scrutinize.

 

2) Risk adjustment vs. medical necessity (talking past each other)

 

Clinicians may code chronic conditions they evaluated and managed; payers may argue those conditions weren’t truly “addressed” at that visit. Depending on the rubric, both positions can be technically correct, one focusing on clinical reality, the other on documentation signals tied to payment rules.

 

3) Retrospective vs. concurrent standards (time travel problems)

 

Retrospective reviews look months or years back, often applying standards that evolved after the date of service. Teams must defend documentation created under older expectations, which feels unfair but happens frequently.

 

4) Intent vs. error (not all misses are fraud)

 

Many discrepancies are workflow or documentation habits, not malice. Yet outcomes can still be punitive, breeding mistrust when honest mistakes are treated like compliance failures.

 

 

Bottom line: Show why the diagnosis is clinically appropriate for this encounter and how you’re actively managing it. That’s the safest ground across these gray zones.

How do insurer audits differ from CMS/RADV audits?

 

It’s easy to lump them together, but payer audits and CMS/RADV reviews differ sharply in intent and consequence.

 

Aspect Insurer/Payer Audit CMS/RADV Audit
Intent Reduce future risk and clean up submissions Test compliance, recover overpayments
Outcome Coaching or filtering Punitive; repayment possible
Pros Aligns incentives with integrity Deters abuse
Cons Opaque criteria, inconsistent standards Punitive outcomes, repayment risk
Gray Areas Few bright-line rules; unpublished pass/fail reasons Evolving interpretations

 

In short, Payer reviews teach you how to stay compliant. CMS/RADV reviews decide if you have already failed.

 

How Organizations Usually Discover Problems

 

Few groups wait for payers to call. The smart ones look inward first.

 

    • Internal peer review: MDs reviewing APP charts; medical directors sampling notes
    • Coder/scribe flags: Missing elements, mis-placed diagnoses
    • Vendor health checks: Annual or periodic chart reviews
    • Escalation from payers: Higher rejection rates signal systemic issues

 

If CMS is the first to alert you, you’re likely very large and very late.

 

Finding balance: A collaborative path forward

 

Since no one outside the auditing entities has the full rubric, prevention is the only reliable path forward. Treat “supported” as the floor, not the finish line, and show medical relevance and active management.

 

Audits live in uncertainty by design. You can’t force transparency, but you can control documentation culture. Don’t stop at “a code is supported.” Prove clinical relevance and active management, review everything quickly enough to make fixes, and define what “enough” means so clinicians aren’t left guessing.

 

Technology now makes this easier. AI-assisted chart reviews, MEAT compliance sensors, and documentation feedback tools can screen 100% of notes, flagging small inconsistencies before they grow. Groups that self-audit regularly, train clinicians on evolving standards, and use these tools to ensure documentation completeness are far better prepared when payers come calling.

 

As payment models grow more complex, understanding audits and using technology to stay ahead turns exposure into stability.

 

If you’re ready to see how technology can make audit readiness part of your everyday workflow, book a demo with DoctusTech and discover what proactive documentation looks like in action.

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Lessons from the 2023 HHS-RADV audit: What Medicare Advantage plans should take away

In the high-stakes arena of risk adjustment, the Department of Health and Human Services (HHS) recently published results from the 2023 benefit year HHS-RADV (Risk Adjustment Data Validation) audit. While these results apply to the HHS risk adjustment program, the findings hold important lessons for anyone involved in Medicare Advantage (MA) and CMS-HCC coding. 

 

The persistent documentation gaps uncovered by HHS are the same cracks that CMS looks for when reviewing Medicare Advantage risk scores. 

 

So what did the 2023 RADV uncover? Let’s take a look at the key findings.

 

Key findings from the 2023 RADV results

 

The 2023 RADV results paint a clear picture of where the cracks in documentation remain.

 

Broader participation, higher stakes

 

In 2023, HHS expanded its audit to include 471 of 596 issuers with risk-adjustment plans, a jump from 463 of 606 in 2022. That means nearly 80% of issuers faced audit scrutiny last year. The trend is clear: broader oversight is becoming the norm.

Persistently miscoded HCCs (Hierarchical Condition Categories)

 

Certain conditions remain top audit targets. HHS found that the most frequently invalidated codes were:

    • Diabetes with chronic complications 
    • Specified heart arrhythmias 
    • COPD / bronchiectasis 

 

These three diagnoses exist in both models, and they continue to trip up coders and providers due to ambiguous documentation, overlooked guidance, or coder inexperience. For MA organizations, the signal is clear: if HHS is flagging them, CMS will too.

Adjustments to risk adjustment transfers

 

Where high error rates were found, HHS adjusted plan liability risk scores and transfers. Issuers with error-prone coding faced reduced payments or retroactive charges, while others saw upward adjustments. Medicare Advantage plans should expect similar mechanics under CMS RADV, especially as oversight expands.

 

And CMS isn’t letting these errors slide. The agency’s response has been to double down, expanding audits and deploying new tools to catch unsupported codes even faster.

 

Rising scrutiny: Why 2025 RADV audits are a game-changer

 

If the 2023 audit was a warning, 2025 is the storm on the horizon. CMS isn’t just adjusting; it’s escalating. Recent announcements confirm that:

 

    • All eligible Medicare Advantage plans will be audited annually, up from just around 60 plans per year.
    • CMS aims to clear its audit backlog for Payment Years 2018 through 2024 by early 2026.
    • The volume of records per audit is expanding, potentially up to 200 records per plan—amplifying documentation demands.
    • CMS is deploying AI and machine learning tools and scaling its workforce from dozens to nearly 2,000 coders by September 2025.

 

For providers, this means the days of hoping your health plan’s audit will cover you are over. CMS is coming with sharper tools, more auditors, and a longer memory. The backlog of audits from 2018 through 2024 will be closed by 2026. That’s nearly a decade of risk converging all at once.

 

These changes dramatically heighten the risk profile for both Medicare Advantage Organizations and at-risk providers, particularly those in shared-risk or value-based arrangements, as they face potential claw-backs on prior years and reduced future income.

 

Why the tougher stance? Because the same errors keep showing up year after year. The most common miscoding pitfalls tell the story.

 

Common miscoding pitfalls and their roots

 

Every unsupported diagnosis CMS flags in a RADV audit has a backstory. Rarely is it outright fraud; more often, it’s the small cracks in documentation and coding that add up. HHS-RADV flagged the same root causes that CMS auditors see: 

 

    1. Vague consultation documentation

      Diagnosis codes must be fully supported by clear, dated, and signed clinical notes, not just shorthand terms or unexplained abbreviations.

    2. Failure to follow coding clinic guidance

      Even when guidance exists —such as for Diabetes with Chronic Complications— misunderstanding or ignoring it leads to repeated errors.

    3. Overlooked HCC aggregations

      Coders sometimes fail to collapse overlapping conditions appropriately (when applicable), inflating chronic condition counts.

    4. Coder inexperience

      Coding staff unfamiliar with CMS requirements or nuanced ICD‑10 conventions continue to make misclassification errors.

In isolation, these missteps might look like small clerical slips. But RADV audits magnify them, turning documentation shortcuts into revenue risk. For providers and health plans, the lesson is clear: unless the roots of miscoding are addressed through education, workflow support, and real-time feedback, the same mistakes will keep surfacing, and the financial exposure will only grow.

 

On the surface, these may look like minor slips. But under RADV’s microscope, each miscode can snowball into clawbacks, strained contracts, and compliance risk.

 

Downstream impact on providers: What’s at stake

 

For providers, the real shock of a RADV audit often doesn’t come from the initial findings. It comes from the ripple effects. What appears to be a single unsupported diagnosis on paper can quickly escalate into financial, operational, and even legal consequences. Let’s dig deeper on what’s at stake:

 

    • Financial exposure through shared-risk contracts. Providers may inadvertently trigger overpayment recoupments if plans are audited and found to be outliers.
    • Administrative burden from documentation requests. With audit scopes expanding, clinics and hospitals face heavier demands for chart retrieval and note validation.
    • Contract renegotiations and trust erosion. Payers may reevaluate shared-risk arrangements if documentation accuracy (and, by extension, compliance) falls short.
    • Increased liability risk. Failure to support diagnoses not only damages reimbursement but can also trigger Stark Law or False Claims Act scrutiny.

 

 

In short, RADV audits don’t just test documentation accuracy; they test the resilience of an entire organization. Providers who treat them as someone else’s problem risk discovering too late that the financial and reputational fallout lands squarely at their doorstep.

 

As CMS sharpens its audit tools and scales its oversight, providers must bolster documentation and coding defenses, and fast. The 2023 RADV data, especially around persistent miscoded HCCs like Diabetes, Arrhythmias, and COPD, reveal where coding vulnerabilities remain. Without swift intervention, the financial and contractual fallout could be severe.

 

That’s why organizations need tools that don’t just catch errors after the fact, but prevent them at the point of care.

 

Turning Documentation Into a Strength

 

The 2023 HHS-RADV results spotlight the same weak points that Medicare Advantage plans must address. For providers, the way forward isn’t chasing errors after the fact; it’s building systems that prevent them at the point of care.

 

That’s why, at DoctusTech, we build AI-powered solutions that transform documentation from a liability into an advantage:

 

    • Learning app & personalized training: Clinicians learn HCC coding in minutes, not months, with on-demand lessons tailored to their real gaps.
    • AI diagnosis assistant: Embedded in your EMR, it surfaces patient history, prompts for codes, and translates charts in real time. Less clicking, more compliance.

 

Each tool stands strong on its own, but together they create a system that protects providers from miscoding errors and audit exposure without slowing down clinical workflows.

 

Ready to protect your organization? Get a Free Demo of DoctusTech’s HCC Coding Solutions today.

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CMS accelerates RADV audits: What unsupported diagnoses mean for MA plans

The Centers for Medicare & Medicaid Services (CMS) just issued a serious wake-up call to all Medicare Advantage (MA) plans: Starting now, every eligible MA contract will be audited annually, and CMS is rapidly closing the books on a backlog of Risk Adjustment Data Validation (RADV) audits stretching from 2018 to 2024.

 

This change marks a sharp pivot from a previously slow and selective audit approach to an aggressive, full-scope enforcement strategy. So, what’s driving this shift? And what exactly are “unsupported diagnoses,” the root cause of billions in overpayments?

 

Let’s break it all down.

What changed? A new era of RADV enforcement

 

For years, CMS lagged in RADV audits. The last significant recovery of MA overpayments came from audits on 2007 data. Meanwhile, federal estimates suggest MA plans may be overbilling the government by $17–$43 billion each year.

 

CMS is now scaling up fast:

 

    • All MA contracts will be audited every year going forward.
    • Audits from 2018–2024 will be completed by early 2026.
    • The coding team is expanding from 40 to 2,000 staff.
    • Each audit will now include 35–200 charts per plan, depending on size.
    • Technology and AI will help flag suspicious/unsupported diagnoses in submitted claims.

 

The goal? To recover overpayments and hold plans accountable for the accuracy of the diagnoses they submit.

 

Why are unsupported diagnoses the target?

 

If you’re reading this, you probably already know that MA plans are reimbursed based on their members’ RAF scores, which are calculated using the Hierarchical Condition Categories (HCC) model, and that the plans get reimbursed more money to provide care for their sicker patients (i.e., those that have more conditions or more severe conditions).

 

But here’s the catch: Those diagnoses must be clinically documented and relevant to the patient’s care. If a diagnosis is not supported by medical documentation, it’s considered “unsupported”—and therefore ineligible for payment.

 

That’s why RADV audits zero in on one thing: Are the diagnoses you’re getting paid for actually supported in the chart?

 

It’s not enough for a condition to exist, it has to be documented with clinical relevance and intent to treat.

 

But in practice, that’s where things get confusing. Many unsupported diagnoses aren’t the result of fraud; they’re just the result of gaps in everyday workflows that go unchecked.

 

Let’s look at 4 common ways unsupported diagnoses show up in charts and how they can put your plan at risk.

4 Common use cases (and misuses) of unsupported diagnoses

 

Let’s explore where unsupported diagnoses appear and how they impact value-based care programs.

 

1. Auto-populated diagnoses (without clinical relevance)

 

Many EHRs allow auto-populating diagnoses from prior visits. While this speeds up documentation, it often leads to chronic or resolved conditions being pulled forward without evaluation or treatment, making them unsupported.

 

Example: A patient’s chart still lists “Major depressive disorder, moderate, recurrent episode” in the assessment and plan section of the note, but there’s no assessment, treatment, or mention in today’s note. That HCC should not be added to today’s note or submitted.

 

2. Historical diagnoses without ongoing impact

 

Diagnoses must be active during the encounter. Resolved conditions without current relevance can’t justify payment unless specified and supported.

 

Example: A patient had prostate cancer treated 5 years ago and is now cancer-free. If the patient is not on adjuvant therapy, then the active cancer diagnosis is unsupported and should be switched to history of prostate cancer.

 

3. Coding from lab values or imaging alone

 

Coders sometimes extract diagnoses from labs or imaging reports. However, a diagnosis needs to be made and documented by an eligible provider —typically MDs, DOs, NPs, or PAs—in a face-to-face visit, not inferred from a value. Diagnoses from scribes, MAs, or unlicensed staff aren’t valid.

 

Example: An eGFR of 55 appears in labs, but if the provider doesn’t document CKD stage 3a in the note, it’s not valid for risk adjustment.

 

4. Conditions without evaluation, assessment, or plan

 

Even if a condition is listed in the note, it’s unsupported if it isn’t evaluated or addressed. The recommended standard is the MEAT criteria (Monitoring, Evaluation, Assessment, Treatment).

Example: “Heart failure” is on the diagnosis list, but there’s no mention of symptoms, exam findings, or medication adjustments. That’s an audit risk.

 

What’s at stake?

 

CMS is not just validating diagnoses—they’re using audit results to extrapolate overpayments across entire plans. That means a few unsupported diagnoses in a 100-record sample could result in millions in repayment demands.

 

Plans that haven’t taken RADV seriously will be playing catch-up fast. The cost of non-compliance is no longer theoretical—it’s actionable.

 

How can you be prepared?

 

If you’re in population health, risk adjustment, or care delivery leadership, now is the time to:

 

1. Retrain providers on MEAT documentation

Help them understand which documentation is compliant for HCC coding and which isn’t.

2. Audit high-impact diagnoses internally.

Use retrospective chart audits to flag unsupported codes before CMS does.

3. Invest in Clinical Documentation Improvement (CDI)

CDI teams can help bridge gaps between documentation and coding accuracy.

4. Scrutinize vendor-coded charts

Not all external coders understand the nuance of HCC rules. Spot check their work.

5. Embrace RADV readiness as a continuous process.

With yearly audits now guaranteed, RADV prep isn’t a one-time event. It’s an operating requirement.

6. Leverage AI tools that do the heavy lifting.

AI-powered platforms like DoctusTech can transform your RADV readiness by checking 100% of charts in real time, ensuring HCCs are properly supported, and more.

 

Final thoughts: This is about accountability

 

CMS is sending a clear message: If you want to participate in a program that rewards managing patient risk, your documentation must prove it.

 

Unsupported diagnoses erode trust in the MA program and jeopardize funding meant for high-risk care. On the other hand, accurate documentation builds a sustainable model that rewards true clinical complexity and improves outcomes.

 

RADV audits aren’t just about clawbacks. They’re about accountability.

 

And for MA plans committed to integrity and quality care, that’s an opportunity, not a threat.

 

At DoctusTech, we help provider organizations and health plans improve HCC coding accuracy without adding an administrative burden to clinical teams.

 

With our mobile learning app, providers get brief, case-based training that fits into their day, reinforcing how to document and code diagnoses per CMS’s expectations. Our platform helps:

 

    • Reinforce MEAT documentation standards using real-world scenarios
    • Reduce unsupported diagnoses through more innovative education, not more paperwork
    • Improve RAF accuracy while staying compliant with V28 and RADV rules

 

It’s not just about coding education. It’s about empowering providers to get it right the first time, which protects your organization from overpayment risk and helps ensure patients receive the care they need.

 

Want to see how it works? Schedule a demo and see how DoctusTech helps you stay ahead of CMS’s RADV expansion.

 

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Risk Adjustment Refresher Course: How To Do It Right

You’ve done training before, but documentation errors keep creeping in. Charts are missing key HCC codes, chronic conditions aren’t being redocumented, and you’re starting to wonder—will we be scrambling at the end of the year to fix all this? Sound familiar?

 

That’s precisely why a Risk Adjustment refresher course exists. They’re not just another box to check off; they’re a way to keep risk adjustment top of mind for your team, improve documentation habits, and make sure your team is set up for success—without a last-minute panic.

 

Let’s explore what makes a practical refresher course, how to structure it, and how to measure its impact.

Understanding the Role of a Risk Adjustment Refresher Course

 

A Risk Adjustment refresher course shouldn’t be a boring PowerPoint presentation about HCC coding. It’s a strategic touchpoint to reinforce best practices and help teams avoid common documentation pitfalls. Done right, it can mean the difference between a smooth, well-documented year and a frantic scramble to correct errors before submission deadlines.


For example, if you notice that documentation rates are lower than expected by Q1, you can run a refresher course focusing on redocumentation, workflow improvements, and CMS compliance. This way, clinicians can work toward improving their HCC coding accuracy and avoid an end-of-year crunch by maintaining consistent documentation throughout the year. 

How Often Should You Run a Risk Adjustment Refresher Course?

 

Most teams schedule a Risk Adjustment refresher course at least once a year, but successful organizations integrate them more frequently:

 

    • Quarterly Check-Ins: These are structured sessions designed to dive into performance metrics, documentation trends, and improvement areas. Leadership teams, clinical directors, and coding specialists review redocumentation rates, audit findings, and CMS guideline adherence to ensure the organization is on track.

 

    • During Morning Huddles: These brief but focused meetings integrate risk adjustment updates into daily workflows. They highlight immediate concerns, such as specific documentation gaps, coding errors, or upcoming CMS compliance changes, ensuring real-time course correction.

 

    • On-Demand Learning: A flexible solution that benefits all organizations. Small practices appreciate its practicality, as clinicians can learn at their own pace without disrupting patient care. Large healthcare systems value its scalability, allowing multiple locations and teams to receive standardized training. One solution that fits all is the DoctusTech Learning App, preferred by 9 out of 10 clinicians.

 

    • Case-Based Discussions: Highly beneficial for specialists (e.g., cardiologists, endocrinologists) working within VBC models. Reviewing real patient cases ensures that documentation aligns with both clinical and risk adjustment requirements. In primary care, case-based discussions can be equally impactful when tailored to address specific documentation gaps, such as under-documentation of major depressive disorder.

 

5 Key Ingredients of an Effective Refresher Course

 

1. Reinforce the “Why” Behind Risk Adjustment

 

Let’s be honest—clinicians and coders are busy. If they don’t see the value, they won’t engage. A good refresher starts by connecting documentation back to what matters:

 

    • Better Patient Care: Ensuring conditions are properly documented leads to better treatment and follow-up.
    • Financial Impact: Without proper documentation, known chronic conditions won’t be reimbursed, leaving money on the table.
    • Compliance Risks: Missing redocumentation can mean non-compliance, audits, and clawbacks.

 

2. Address Common Documentation Pitfalls

 

If you had to pick one thing to focus on in a refresher, it should be redocumentation. Too often, chronic conditions from the previous year aren’t re-recorded, leading to missed reimbursement opportunities. Providers risk losing credit for previously diagnosed conditions without re-documentation, ultimately impacting risk scores and reimbursement accuracy.

 

To put this into perspective, consider the following scenario: Your team currently documents only 28% of chronic conditions annually, which means that 72% go unreported, leading to gaps in patient care and lost revenue.

 

So, what can you do to fix this? Here’s how to approach it:

 

    • Set Clear Goals: Aim to redocument at least 95% of chronic conditions annually.
    • Analyze Past Performance: Review last year’s documentation and compare it to the current year’s HCC submissions. Identify missing chronic conditions and implement structured reminders.
    • Reinforce Best Practices: Encourage clinicians to consistently review past diagnoses and document conditions accurately during visits where time allows. Another option is to take advantage of your scheduled check-ins, such as annual wellness exams or routine checkups, to have more opportunities to focus on comprehensive documentation.

 

Beyond redocumentation, there are other documentation pitfalls that refresher courses should address:

 

    • Not specifying diagnoses (e.g., using “unspecified depression” instead of “major depressive disorder, recurrent, moderate”).
    • Incomplete screening and lab orders, leading to missed coding opportunities.
    • Lack of documentation for conditions that impact risk scores, which affects reimbursements and compliance.

 

3. Make Workflows More Efficient

 

Many documentation errors happen because workflows aren’t optimized. A Risk Adjustment Refresher Course could:

 

    • Identify where documentation is breaking down.
    • Reinforce clinic workflows to ensure proper HCC coding at the point of care.
    • Highlight small workflow changes that have a significant impact (e.g., structured templates in the EMR to ensure required documentation is included).

 

4. Stay Aligned with CMS Guidelines & Coding Updates

 

CMS updates its guidelines every year, and staying ahead of these changes is critical. A refresher course should:

 

    • Summarize major updates (e.g., the addition of “Class 3 Obesity” as a new ICD-10 code).
    • Explain how these updates affect documentation and reimbursement.
    • Provide easy-to-follow guidance for clinicians on adapting to changes.

 

5. Use Engaging Teaching Methods

 

Nobody wants to sit through a dry, technical lecture. Make refresher training engaging and practical:

 

    • Case-Based Learning: Walk through real patient scenarios.
    • Microlearning Modules: Short, focused lessons clinicians can complete in minutes.
    • Quizzes & Gamification: Make learning interactive.
    • Customized Learning Paths: Tailor training based on common documentation gaps in your organization.

 

How to Measure the Impact of a Refresher Course

 

Training is only valuable if it leads to measurable improvements. Here’s what to track:

 

1. Redocumentation Rates

 

    • Metric: The percentage of previously diagnosed HCC conditions was redocumented this year.
    • Target: 95% or higher.
    • Actionable Insight: If redocumentation is low, find out why clinicians are forgetting, or use software that helps you automate this goal such as DoctusTech’s PDAP.

 

2. Coding Accuracy & Specificity

 

    • Metric: Reduction in unspecified diagnosis codes.
    • Target: More detailed diagnoses (e.g., “major depressive disorder, recurrent, moderate” instead of “unspecified depression”).

 

3. Number of New HCC Codes Captured

 

    • Metric: Number of new chronic conditions documented per patient visit.
    • Consideration: This varies—clinics new to HCC coding may capture more than established ones.

 

4. Compliance & Internal-Audit Performance

 

    • Metric: Percentage of charts flagged for coding inaccuracies pre- and post-training.
    • Insight: Documentation errors should decrease over time if refresher courses are practical.

 

These are basic KPIs to monitor before and after your refresher course to check if it works and identify areas for improvement. However, if you want to go deeper into metrics and you’re just starting a Risk Adjustment initiative, we recommend the article 4 Essential Risk Adjustment KPIs for Your First 90 Days.

 

When to Implement Additional Retraining

 

Even with regular refresher courses, some teams may need extra help. Consider retraining when:

 

    • Redocumentation rates drop below expected levels.
    • Certain conditions are underreported compared to regional benchmarks.
    • Audits reveal frequent coding mistakes or unspecified codes.
    • CMS guideline updates require immediate adaptation.

 

Final Thoughts

 

A great refresher course isn’t just about reviewing rules—it’s about making risk adjustment easier, more efficient, and more effective. By keeping training engaging, aligning it with real-world workflows, and tracking meaningful metrics, organizations can improve compliance, maximize reimbursements, and ultimately deliver better patient care.

 

A Risk Adjustment Refresher Course doesn’t have to be a chore. When done right, they become a powerful tool for making risk adjustment second nature in your organization. And with DoctusTech’s HCC coding education app, staying on top of your training has never been easier. Delivered weekly right to your phone, our app provides individualized learning to help VBC organizations like yours increase RAF accuracy by 30%.

 

Try DoctusTech’s app for free for 14 days and see how our solutions can enhance your approach to risk adjustment.

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4 Essential Risk Adjustment KPIs for Your First 90 Days

The first 90 days of implementing a risk adjustment program are critical to laying the foundation for long-term success. Whether your goal is optimizing HCC (Hierarchical Condition Category) coding, improving clinical documentation, or ensuring compliance, tracking the right Key Performance Indicators (KPIs) during this period is essential. These Risk Adjustment KPIs help measure progress, identify quick wins, and highlight improvement areas.

 

But why is it crucial to focus on KPIs during this initial phase? Let’s explore how tracking metrics can shape the success of your risk adjustment implementation and ensure your organization stays on the path to achieving its goals.

The Importance of Tracking Risk Adjustment KPIs Early

 

KPIs help establish a clear baseline for improvement, allowing organizations to measure progress and evaluate the program’s impact over time. By identifying metrics like HCC capture rates or coding accuracy, healthcare teams gain data-driven insights to prioritize efforts, focus on underperforming areas, and allocate resources effectively. This approach ensures that you can address early challenges systematically, avoiding wasted time and effort.

 

Monitoring progress is also critical to driving accountability and engagement across teams. Risk adjustment success depends on collaboration between clinicians, coders, and operational leaders. Tracking metrics like clinician engagement ensures that everyone is aligned and working toward shared goals. Celebrating early wins, such as improved coding practices or standardized workflows, can build momentum and morale. 

 

Simultaneously, monitoring compliance-related metrics mitigates risks, ensuring documentation meets regulatory standards and avoids potential audit pitfalls.

 

Additionally, Risk Adjustment KPIs provide a roadmap for long-term success by enabling scalability and stakeholder confidence. Metrics tracked in the first 90 days help refine processes that can be replicated across clinics and regions. Demonstrating measurable progress through KPIs reassures stakeholders that the program is delivering value and encourages ongoing support. 

 

In this way, these Risk Adjustment KPIs aren’t just short-term tools but the key to creating a sustainable, efficient, and impactful risk adjustment program.

 

Now that we’ve highlighted the importance of tracking KPIs early in the risk adjustment process let’s explore the specific metrics that can drive success.

 

4 Key Risk Adjustment KPIs to Track in Your First 90 Days

 

Let’s explore 4 essential KPIs for the first 90 days of risk adjustment implementation, giving you a clear roadmap to measure progress and optimize outcomes.

1. HCC Recapture Rate

Recapture Rate is the rate at which providers document (code) recurring (or chronic) HCC diagnoses annually. Compare your rates with industry benchmarks to identify outliers and gaps. A standard goal is an 85% recapture rate.

 

Why It Matters: Accurate and yearly documentation of HCCs ensures that reimbursement aligns with patient needs. Without it, chronic conditions may go unaccounted for, leading to gaps in care and inadequate funding. For clinicians, success in the HCC model means consistently monitoring and managing chronic conditions to prevent avoidable hospitalizations.

 

Quick Tip: Keep the active problem list updated to ensure chronic conditions are accurately tracked while preventing acute conditions from cluttering clinician focus. Implement clinical workflows that address chronic conditions during yearly visits, and use software like PDAP to identify chronic conditions that haven’t been documented yet this year. With PDAP, you can increase your Recapture rates by up to 95%.

 

2. Suspect review Rate

When clinicians evaluate or treat a patient’s symptoms, they may encounter flagged conditions that require review. The Suspect Review Rate is a percentage that represents how often providers look at these flagged conditions—whether they confirm them, rule them out, or leave them unresolved. The formula for calculating this rate is: 

 

Suspect Review Rate=Suspects Applied + Suspects Disconfirmed
Total Suspected Conditions ​×100

 

We’ll also explore the concepts of Suspects Applied and Suspects Disconfirmed. These metrics play a role in evaluating suspected conditions and contribute to the overall Review Rate.

 

Why It Matters: In the HCC model, symptoms alone don’t contribute to reimbursement. So, clinicians must document the underlying condition causing the symptoms, whether they or a specialist are treating it. A high review rate ensures that these conditions are accurately captured, reducing missed diagnoses and improving the completeness of patient documentation.

Quick Tip: Use AI-powered suspecting tools to identify potential conditions that need follow-up automatically. These tools will highlight when results are returned and flag instances where symptoms might be underdocumented, helping ensure the underlying condition is captured correctly.

 

3. New Suspected Diagnoses

These metrics are raw numbers that only provide real value when analyzed alongside the Suspect Review Rate. Suspects Applied refers to the conditions clinicians have confirmed as valid, turning them into actual diagnoses, and Suspects Disconfirmed represents the conditions that were ruled out or determined to be inaccurate. To calculate these metrics, you need a software solution ensuring a clear view of clinicians engaging with suspected conditions. 

 

Why It Matters: A high Review Rate but low Applied Suspects suggests clinicians are rejecting most suspects. This could signal one of three issues:

 

Knowledge Gap – Clinicians may not fully understand the condition or suspecting criteria.

      • Solution: Provide targeted education on suspect criteria and clinical guidelines to improve confidence in applying diagnoses.

 

Workflow Gap – Clinicians struggle to access necessary patient data at the point of care.

      • Solution: Deploy AI tools that surface relevant clinical data in real time, streamlining the review process.

 

Time Constraints – Clinicians may not have enough time to properly review suspects.

      • Solution: Re-evaluate workflows to ensure clinicians can review flagged conditions during Annual Wellness Visits (AWVs) or other key touchpoints.

 

On the other hand, a low Review Rate but high Applied Suspects indicates that while clinicians accept most suspects, they are reviewing too few cases. This may point to workflow inefficiencies, bottlenecks, or system issues preventing broader engagement

 

Quick Tip: Regularly review suspect acceptance and rejection patterns to identify trust gaps or workflow bottlenecks. If clinicians frequently disconfirm suspects, refine the criteria. If review rates are low, investigate process inefficiencies or system limitations.

 

4. Suspects Addressed

You need software to help you monitor this KPI, but tracking potential conditions while they are being worked up avoids conditions being lost in referrals or pending testing. Not every suspected diagnosis turns into an actual condition, but suspected conditions need to be worked up, i.e., you can turn suspects into diagnoses (or rule them out). This KPI tracks how many have been reviewed and resolved.

 

Why It Matters: It ensures providers follow up on potential diagnoses and document HCCs compliantly, preventing missed codes. Addressing suspects promptly helps avoid overlooked diagnoses, ensuring accurate risk scores while maintaining proper documentation practices

 

Quick Tip: Leverage software to automate workflows that assign suspected conditions to the right provider, streamlining the review process and ensuring faster resolution.

 

How Technology Helps You Track These KPIs

 

Tracking these KPIs manually is like navigating a maze without a map—time-consuming, frustrating, and prone to errors. That’s where technology comes in. With the right tools, clinicians can focus on patient care while ensuring accurate documentation, optimized risk scores, and maximized reimbursements. This is where a dashboard with all these metrics comes in handy—and DoctusTech has already built it for you.

 

Meet DoctusTech’s HCC Patient Diagnosis Assist Platform (PDAP)

 

PDAP is an HCC coding software with AI-powered features designed to streamline workflows, boost RAF accuracy, and enhance clinician engagement—all while ensuring compliance. But what makes it a game-changer?

 

    • A Smarter Way to Track KPIs – The PDAP Dashboard provides real-time visibility into all the critical metrics we just discussed—Suspect Review Rate, Recapture Rates, New Suspected & Hidden Diagnoses, and more. No more guesswork—just clear, actionable insights.

 

    • Less Time on Documentation, More Time for Patients – With AI-powered automation, PDAP saves clinicians up to 2.5 hours per week by streamlining chart reviews, surfacing the right diagnoses, and eliminating redundant workflows.

 

    • Real-Time Alerts for Compliance & Accuracy – PDAP ensures that no diagnosis falls through the cracks. It cross-references clinical data, flags non-compliant notes, and integrates seamlessly with 70+ EMRs, ensuring every recapture is timely and accurate.

 

    • Proven Results in Just 6 Months – Organizations using PDAP have seen a 92% Chronic HCC Recapture Rate, a 90% clinician engagement rate, and dramatically improved risk adjustment accuracy.

 

 

Instead of juggling spreadsheets and manual processes, let PDAP do the heavy lifting. With real-time insights and automated workflows, providers can seamlessly close documentation gaps, ensure RAF accuracy, and improve patient outcomes without extra administrative burden.

 

Final Thoughts: Building a Foundation for Long-Term Success

 

Implementing a risk adjustment program is a journey, but tracking the right KPIs during the first 90 days provides a roadmap for success. From coding accuracy and clinician engagement to compliance and financial impact, these metrics help identify challenges, validate strategies, and highlight areas needing optimization.

 

Remember, success lies in achieving KPIs and creating a culture of continuous improvement. By focusing on data-driven insights and fostering collaboration among clinicians, coders, and operational leaders, your organization can maximize the value of its risk adjustment program. Curious about how PDAP can transform your workflow? Let’s talk!

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Your First 30 Days in Risk Adjustment: What You Need to Know

A successful risk adjustment program doesn’t happen by chance—it requires a structured, strategic approach. The first 30 days are critical for establishing a strong foundation, aligning key stakeholders, and setting the stage for long-term success.

 

Laying the groundwork early helps organizations sidestep common pitfalls, streamline operations, and seamlessly transition to an optimized risk adjustment strategy. By following a clear, proactive roadmap, teams can tackle challenges head-on and set achievable goals for continuous improvement.

 

This guide breaks down the essential steps to maximize impact in the crucial first month—helping you drive accuracy, compliance, and financial performance from day one.

 

Why the First 30 Days Matter

 

A well-structured action plan in the first 30 days is critical to ensure that risk adjustment efforts are practical and sustainable. This period allows organizations to establish a clear direction, identify potential challenges, and implement solutions before inefficiencies become entrenched. 

 

Without a defined roadmap, healthcare providers may struggle with inconsistent coding practices, lack of clinician engagement, and missed opportunities for accurate documentation. Organizations can ensure better financial outcomes, compliance, and patient care by setting clear objectives and taking deliberate actions.

 

The next step is breaking down the 30-day process into manageable phases. 

 

Week-by-Week Overview

 

A week-by-week approach ensures that each critical component, from data analysis to training and evaluation, is tackled systematically, maximizing efficiency and long-term success.

 

Week 1: Data Analysis & Identifying Gaps

 

The first week focuses on understanding existing coding practices, identifying discrepancies, and pinpointing outliers. By conducting a thorough data analysis, organizations can establish benchmarks and determine the most pressing areas for improvement.

 


1. Assess Current Coding Practices

    • Conduct a data analysis to understand existing coding trends.
    • Compare diagnosis prevalence to regional or national prevalence rates in a comparable population.
    • Identify variations in coding accuracy among different clinics and providers.2. Recognize Key Outliers
    • Determine which providers or clinics have significantly different coding rates.
    • Investigate whether outliers are due to documentation gaps, lack of training, or operational limitations (e.g., missing diagnostic tools).
    • Address immediate discrepancies to ensure standardization.

2. Review HCC Code Prioritization

    • Identify high-impact conditions that are underreported.
    • Develop a priority list of prevalent conditions that can be easily diagnosed, documented and treated.

 


Quick Tip: For a deeper understanding of the official guidelines and risk adjustment methodology, organizations can refer to the Centers for Medicare & Medicaid Services (CMS), which provides an authoritative resource on HCC coding and the CMS risk adjustment model. This can guide your efforts in aligning coding practices with national standards and ensuring accuracy in reporting.


Week 2: Establishing Education & Training Plans

 

The second week is dedicated to developing a structured training program tailored to different roles. This includes defining training objectives, choosing effective teaching formats, and ensuring leadership buy-in to drive engagement and adherence to coding best practices. 

 

3. Define Training Needs

    • Identify knowledge gaps in clinical and coding teams.
    • Develop educational content tailored to different roles (e.g., clinicians vs. coders).
    • Establish training goals that align with compliance and accuracy improvement.


4. Choose an Effective Training Format

    • Decide between one-on-one coaching, workshops, or digital learning platforms.
    • Consider a hybrid approach if resources allow.
    • Ensure the format aligns with organizational culture and clinician workflow.


5. Gain Leadership Buy-in

    • Engage medical directors and clinical leadership in decision-making.
    • Address potential resistance by explaining the benefits of improved coding accuracy.
    • Standardize controversial HCC coding decisions to avoid inconsistencies across providers.


Quick Tip: Training is most effective when teams access interactive, on-demand learning tools. Organizations can refer to the DoctusTech Learning App to provide clinicians and coders with engaging, self-paced education to master HCC coding and risk adjustment best practices, all while fitting seamlessly into busy schedules.


Week 3: Implementation & Operational Adjustments

 

Organizations begin standardizing screening processes in the third week and refining documentation workflows. This phase ensures that newly implemented practices are seamlessly integrated into day-to-day operations.


6. Standardize Screening 

    • Implement standardized screening protocols for common HCCs.
    • Ensure your organization follows a uniform approach in conducting tests such as PHQ-9 for depression or spirometry for COPD.
    • Remove operational bottlenecks by ensuring necessary tools and resources are available.


7. Establish Documentation Standards

    • Provide clear guidelines on what constitutes an acceptable diagnosis for HCC coding.
    • Train clinicians on evaluative statements and documentation best practices.
    • Address compliance concerns by emphasizing correct coding procedures to
      prevent overcoding.

 

Quick tip: To align with best practices, organizations can reference the CMS Data Principles and Operating Norms, which provide key guidelines on data governance, accuracy, and integration. Establishing standardized workflows based on these principles helps improve documentation quality, streamline coding processes, and enhance compliance across teams.

 

Week 4: Evaluation & Refinement

 

The final week focuses on assessing the effectiveness of the implemented strategies. Organizations can refine their approach and make necessary adjustments to sustain improvements over time by gathering feedback, monitoring performance, and leveraging technology.


8. Implement a Real-Time Feedback Loop

    • Develop a system for clinicians to receive feedback on coding accuracy.
    • Consider leveraging chart reviewers, AI-powered coding tools, or internal audit teams.


9. Leverage Technology for Sustainability

    • Utilize coding support tools such as AI-driven suggestions or workflow automation.
    • Encourage the use of structured templates for more straightforward documentation.
    • Ensure clinicians have access to up-to-date coding resources and guidelines.


Quick Tip: To stay compliant and avoid documentation discrepancies, healthcare organizations can use DoctusTech’s PDAP, an AI-powered tool that enhances RAF accuracy and reduces documentation time. Seamlessly integrating with 70+ EMRs, PDAP streamlines workflows, minimizes errors, and provides real-time alerts for non-compliant notes.


Final Thoughts: Setting the Stage for Long-Term Success


The first 30 days of an HCC coding initiative are critical in laying the groundwork for success. Organizations can ensure improved accuracy, compliance, and financial performance by implementing effective training, standardizing operations, and refining processes. 

 

Also, consider that, beyond the first month, ongoing evaluation becomes essential. Tracking key metrics helps assess the impact of training on clinic revenue, ensuring that education efforts strike the right balance between effectiveness and clinical productivity. Regular performance monitoring allows organizations to measure coding improvements, identify areas needing additional support, and adjust strategies to maintain engagement and effectiveness.

 

A well-structured risk adjustment program not only enhances reimbursement outcomes but also improves patient care through better documentation and diagnosis practices.

 

We know navigating risk adjustment can feel overwhelming, but you don’t have to do it alone. DoctusTech is here to help. Schedule a demo with us today and see how we can streamline your HCC coding initiatives for long-term success.

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How to Achieve Accurate HCC Coding with AI

Accurate HCC Coding

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 these challenges, streamlining workflows and improving coding accuracy. 

 

This article will explore how AI can help achieve accurate HCC coding, ultimately leading to better patient care and optimized operational performance.

 

A Reminder: Why Accurate HCC Coding Matters

The HCC model assigns specific codes to patients’ documented health conditions, quantifying their overall health risk. These codes are used to calculate risk-adjusted factor (RAF) scores, which directly influence funding levels from the Centers for Medicare & Medicaid Services (CMS).

 

For VBC organizations, properly documented codes align reimbursements with the costs of managing chronic illnesses, enabling providers to deliver high-quality care. Conversely, inaccurate coding can result in underfunding, compliance risks, or penalties.

 

Beyond financial implications, accurate HCC coding significantly impacts patient care. It provides a comprehensive view of the patient’s health status, enabling clinicians to design personalized treatment plans that address both immediate needs and long-term risks. Proper coding also facilitates better care coordination, reducing hospital readmissions and improving overall outcomes.

 

Given HCC coding’s financial and clinical importance, leveraging technology to achieve accurate HCC coding has become critical for healthcare organizations working within value-based care frameworks. However, achieving this precision is not without its challenges.

Challenges in Achieving Accurate HCC Coding

Accurate HCC coding can be difficult to maintain, and time constraints are one of the biggest hurdles. Under pressure to code quickly, even the most experienced coders may miss crucial details or make errors.

 

The result? Documentation that doesn’t accurately reflect a patient’s health status and potentially affects care quality. On top of this, information silos across departments can create barriers, making patient data less accessible and increasing the risk of errors.

 

Moreover, managing complex workflows demands seamless coordination between coders and clinicians, who must ensure every relevant detail is included in a patient’s record.

 

Workflow inefficiencies, such as software incompatibilities and communication gaps, can compromise coding accuracy.  Still, providers can save time and reduce errors by automating repetitive tasks and enhancing cross-department communication. AI offers a way to address these challenges and improve accuracy.

 

Four Ways AI Simplifies HCC Coding

AI solutions are key to overcoming the HCC coding challenges. Using AI can simplify complex workflows, reduce manual data review, and ensure more accurate documentation of chronic conditions for patient care.

 

Here are 4 ways AI can address HCC coding challenges:

 

1. Aggregated and Filtered Data

AI platforms can integrate data from various sources, such as EMRs, specialist claims, and lab reports, into a centralized system. Rather than merely aggregating data, these platforms filter and prioritize critical information to support accurate documentation.

 

By identifying relevant health details within clinicians’ notes and patient records, AI helps coders efficiently review and address documentation gaps. Sometimes, this involves correcting errors or identifying coding opportunities for clinicians to address during future patient visits.

 

This collaborative approach enhances the accuracy of chronic condition documentation, resulting in more precise RAF scoring and improved patient profiles.

 

2. Automated Chart Reviews 

Manual chart reviews can be time-consuming and prone to human error, especially when coders must sift through extensive patient records to find specific details. AI-driven automation transforms this process by identifying patterns and extracting relevant information in a fraction of the time.

 

By automating these reviews, AI streamlines documentation, minimizes the chance of errors, and enables coders to focus their expertise on complex cases requiring nuanced human judgment. This approach leads to faster workflows, improved accuracy, and more comprehensive patient records.

 

3. AI-Powered Suspecting 

One of the standout features of AI in HCC coding is its ability to “suspect” potential diagnoses. Using advanced algorithms, AI analyzes patient data to flag conditions that might not be explicitly diagnosed. These suspecting models identify risk factors, trends, or patterns that clinicians can review and decide if the condition warrants further evaluation.

 

Uncovering new and untreated conditions that affect accurate RAF scores helps complete patient profiles and enables organizations to capture the full range of risk adjustment opportunities.

 

4. HCC Recapture

Chronic conditions require consistent tracking and updates to ensure accuracy in coding. AI solutions equipped with HCC recapture capabilities continuously monitor patient data, automatically track relevant conditions, and update patient profiles with the latest information. This feature minimizes the need for coders to revisit records manually and ensures that no HCC codes are overlooked.

 

By keeping profiles up-to-date and accurate, these AI tools enhance RAF scoring while reducing administrative burdens on healthcare teams, but also play a key role in transforming how healthcare systems capture and process data.

 

Impact of AI-Driven HCC Coding Solutions

AI solutions are transforming healthcare by combining advanced algorithms with medical data to improve the accuracy of HCC coding. These tools enable clinicians and coders to capture chronic conditions in real time, ensuring that codes are assigned correctly and reflect the true complexity of a patient’s health status.

 

By automating repetitive tasks, AI enhances the efficiency of processing large volumes of patient data and ensures that every relevant condition is documented accurately. This supports long-term coding precision and allows healthcare teams to dedicate more time to patient care, reducing administrative burdens while improving compliance with value-based care models.

 

Ultimately, we all know that time is a precious commodity for busy clinicians. That’s where AI platforms like DoctusTech’s HCC Patient Diagnosis Assist Platform (PDAP) come in to provide comprehensive solutions that address the key challenges clinicians face in their daily workflows. Here’s how it helps:

 

  • Processes unstructured data.
  • Recaptures HCCs within your native charting workflow. 
  • Automates chart reviews.
  • Streamlines pre-charting with automated suggestions and screening reminders.
  • Unifies patient data from EMRs, payer lists, and historical records.
  • Delivers real-time coding updates to achieve more accurate RAF scores.

 

Ready to streamline your HCC coding process? Discover how DoctusTech’s PDAP can save time and improve your RAF accuracy. Learn More Today.

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How to Prepare for a RADV Audit

Research compliance in the CMS risk-adjustment model and you might come away with more questions than answers. There are few rigid guidelines or clear regulations, leaving Medicare Advantage Organizations (MAOs) in a state of some uncertainty. One thing they can be sure of, however, is that they’ll inevitably face a RADV audit. This blog post explores how to prepare for a RADV audit, the potential consequences of noncompliance, what auditors are looking for, and more.

 

What are RADV audits?

The acronym ‘RADV’ stands for risk adjustment data validation – which hints at the purpose behind these audits. In effect, CMS wants to ensure that documentation is accurate and reliable, that it reflects the diagnosis and management of a patient’s condition, and, therefore, that reimbursement is appropriate to the patient’s estimated cost of care. 

 

Here’s how CMS defines the RADV program:

 

“The Medicare Advantage Risk Adjustment Data Validation (RADV) program is CMS’ primary way to address improper overpayments to Medicare Advantage Organizations (MAOs). During a RADV audit, CMS confirms that any diagnoses submitted by an MAO for risk adjustment are supported in the enrollee’s medical record.”   –   CMS

 

CMS states that they’re looking for ‘risk adjustment discrepancies’ that lead to payment errors – in essence, whether MAOs have been overpaid. 

 

Why are RADV audits important?

RADV audits are important for the same reason that accurate HCC coding is important. The CMS risk-adjustment model only works if MAOs document risk-adjusting conditions appropriately – allowing CMS to accurately calculate each patient’s estimated cost of care, and reimburse providers appropriately. RADV audits help ensure this process is working as it should.

 

From an MAO’s perspective, RADV audits help to reveal overpayment errors due to incorrectly-recaptured acute codes, incorrect initial encounter codes, and exclusion codes coded together.

 

The risk of non-compliance

Complying with CMS’ regulatory requirements will help organizations receive accurate reimbursement, and ensure positive patient outcomes through the correct allocation of resources. Non-compliant organizations, however, risk owing CMS up to three times the overpayment, plus a fine of $11,000 per violation. And as these examples show, fines can really add up:

 

What the auditors are looking for

In a nutshell, CMS wants to ensure that:

  • The diagnosis is accurate
  • The documentation accurately reflects the diagnosis 

 

“The true north is: ‘are the diagnosis and management appropriate’?’ That’s what compliance means, and that’s what auditors are looking for,” explains DoctusTech CEO Dr. Farshid Kazi.

 

But beyond that, the specifics remain frustratingly unclear. “All we can really be sure of are things people have been penalized for previously,” says DoctusTech’s Director of Quality Dr. Adam Steele. “While there are audit standards online and in CMS’ training book, these standards aren’t necessarily the same things we see organizations get penalized for.”

 

This leaves MAOs with little choice but to prioritize specific diagnoses and thorough documentation, accurate HCC coding, and the appropriate care and management of patients’ conditions. 

 

How to prepare for a RADV audit

While hard-and-fast compliance regulations may be thin on the ground, following these best practices can help organizations remain compliant and prepare for a RADV audit.

 

Train and educate staff

  • Provide ongoing HCC education for coders, CDSs, scribes, and clinical staff on documentation and coding best practices.
  • Educate staff on the importance of compliance with RADV audit requirements.

Conduct internal reviews

  • Perform thorough chart reviews to ensure diagnoses submitted for risk adjustment are supported by the appropriate documentation.
  • Hold regular internal audits to identify discrepancies in coding and documentation.

Ensure data integrity and accuracy

  • Ensure ICD-10 codes are accurately assigned based on documented clinical conditions.
  • Confirm that any data submitted to CMS matches patients’ medical records.

Develop a response plan

  • Assemble a dedicated audit response team with clearly defined roles and responsibilities.
  • Establish a protocol for responding to audit requests, including timelines and communication strategies.

Hold mock audits

  • Conduct mock RADV audits to identify potential issues and improve your response processes.
  • Use feedback from mock audits to make necessary adjustments in documentation and coding practices.

Use technology

 

If your organization needs help ensuring ongoing compliance and preparing for RADV audits, DoctusTech can help.
Book a demo today.

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Why does accurate HCC coding matter?

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 patients per encounter – with a greater focus on patient outcomes when compared with the ‘numbers game’ of fee-for-service medicine. For many, VBC captures why they became doctors in the first place. But for some, the documentation requirements associated with the value-based care model stand in the way.

 

“The documentation is intimidating,” agrees the Chief Clinical Officer of a leading at-risk physician group. “And it wasn’t something that providers learned in medical school.” The ‘intimidating documentation’ around HCC coding is highly off-putting to providers. They don’t care about it, they don’t want to learn it, and they’d rather be spending time with patients. So why does accurate HCC coding matter, and how can we make clinicians care about it?

 

The problem

 

Physician burnout remains a major issue, and it’s clear that the accumulation of non-clinical tasks is a significant contributing factor. As an example, a recent study from the American Journal of Medicine reports that primary care physicians spend an average of two hours interacting with an EMR for every hour of patient contact – that’s 4.5 hours each day in the clinic, with an additional 90 minutes at home every evening. This quote from the same report puts the problem into context:

 

“I am no longer a physician but the data manager, data entry clerk and steno girl… I became a doctor to take care of patients. I have become the typist.”
American Journal of Medicine

 

With physician burnout rates reportedly as high as 63%, it’s hardly surprising such attitudes persist. In the value-based care model, learning the intricacies of risk adjustment and maintaining accurate documentation represents another time-consuming task for clinicians. That’s why it’s so crucial that they understand and appreciate the value of accurate HCC coding.

 

Accurate HCC coding and reimbursement

 

“In addition to helping predict healthcare resource utilization, RAF scores are used to risk-adjust quality and cost metrics. By accounting for differences in patient complexity, quality and cost performance can be more appropriately measured.”
– American Academy of Family Physicians

 

The first and most obvious point to make here is that accurate HCC coding has a direct influence on reimbursement. The risk-adjustment model depends on all risk-adjusting conditions being coded accurately – ensuring each patient has a risk score that suitably reflects their likely cost of care. Therefore, accurate coding ensures that healthcare services are appropriately reimbursed for the level of care provided to patients. In a nutshell, clinicians and other medical staff should care about accurate HCC coding because it ensures they get paid.

 

Inaccurate coding, meanwhile, can lead to under- or overpayment – either of which can be highly damaging to an organization’s financial stability.

 

Accurate HCC coding and compliance

 

While HCC compliance regulations can seem vague or confusing, the most common causes of audit failure include the following:

  1. Under-documented chronic conditions
  2. Incorrectly-recaptured acute codes
  3. Incorrect initial encounter codes
  4. Exclusion codes coded together
  5. Inclusion codes missed

Accurate HCC coding, therefore, is a matter of regulatory necessity if organizations are to avoid penalties and other legal repercussions. While compliance isn’t necessarily the most powerful motivator for reluctant clinicians, it is an important reminder that accurate HCC documentation is non-negotiable for VBC organizations.

 

Accurate HCC coding and patient care

 

“Accurate diagnosis coding can help your team identify high-risk patients and give them the right care at the right time.”
– American Academy of Family Physicians

 

This final point is likely the one that will resonate most powerfully with clinicians and other clinic and hospital staff. At its heart, the value-based care system is about reducing costs and increasing the quality of patient care.

 

As a part of that, accurate HCC coding helps:

 

  • Identify patients at greater risk of certain conditions or complications
  • Implement preventative screenings and lifestyle interventions
  • Minimize hospitalizations and readmissions
  • Ensure patients have access to the appropriate resources for their needs
  • Improve patient understanding and management of chronic conditions
  • Improve care coordination
  • Ensure all relevant providers have access to accurate, up-to-date information on patients’ health status
  • Improve quality reporting and identify areas for improvement

Accurate HCC coding is an unglamorous but essential aspect of value-based reimbursement – helping to support the fundamental promise of value-based care to improve patient experiences and enhance patient outcomes.

 

Improving engagement, getting buy-in

 

“Physician engagement can make or break a hospital’s HCC-capture strategy.”
HFMA

 

It’s clear that accurate HCC coding is vital to the success of accountable care organizations and other VBC providers. But to code accurately, clinicians and other staff must first undergo HCC coding education. The trouble is, traditional methods of HCC training no longer work. Knowledge retention rates for ‘tired and tested’ techniques such as lectures, written materials, and demonstrations range from between 5% and 30% – which is to say nothing of the critical matter of clinician engagement.

 

 

Here at DoctusTech, we employ a revolutionary app-based learning method using a mix of multiple-choice questions and clinical vignettes. This active learning approach generates knowledge retention rates as high as 75%, and better yet, clinicians love it. Our research shows that the DoctusTech app is the preferred method of HCC education for 9 out of 10 clinicians, with an engagement rate of 90%.

 

If you’re struggling to get your clinical staff to care about accurate HCC coding, it’s time you tried the DoctusTech app. Schedule a demo today.

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Exploring blended payments

We asked VBC thought leaders to share their experiences of fee-for-service and value-based reimbursement models. 

 

While value-based payment models are on the rise in the U.S, primary care practices still receive the majority of their payments via fee-for service. In 2022, 70% of primary care physicians reported receiving fee-for-service payments, versus just 46% for value-based payments. Although many health systems are now transitioning to the value-based care model, this transition can’t happen overnight – meaning some combination of both value-based and fee-for-service models is inevitable. In this article, we’re going to explore so-called blended payments in value-based care, and ask whether organizations should persist with them long-term.

 

Are value-based care and fee-for-service incompatible?

 

Value-based care and fee-for-service are often considered to be polar opposite reimbursement models. While the fee-for-service model sees providers receive payment for each service they deliver – regardless of the quality of care or patient outcomes – value-based medicine follows the equation of ‘value = quality ÷ cost’.  That means, under the VBC reimbursement model, providers are rewarded for delivering high-quality care and positive patient outcomes – while effectively managing costs. 

 

In the highly-politicized U.S healthcare landscape, it’s possible to see value-based care and fee-for-service medicine as philosophically incompatible. “The difference is the basic premise of having a transactional relationship with a healthcare provider, versus putting the responsibility of the outcome of that relationship on the healthcare provider,” says Dr. Rayny Ramirez, CEO, Community Medical Group. “At the clinical level, doctors can care less about financials and cost. Doctors just want to be doctors.”

 

Blended payment: a marriage of inconvenience

 

The transition to value-based healthcare slowed during the turmoil imposed by the COVID-19 pandemic, but this was never a rapid process to begin with. Medical Economics describes how the industry has “inched toward” value-based healthcare over the last decade “on an incremental basis”. This slow shift has left many organizations in a kind of limbo, forced to operate blended payment models comprising both value-based and fee-for-service payments. Although a marriage of convenience, these blended payment models could potentially explain recent criticism of VBC success rates, says the Chief Clinical Officer of a leading at-risk physician group who prefers to remain anonymous.

 

“I wonder if they’re trying to do both,” she tells us. “I wonder if they’re trying to do this treadmill of fee-for-service and – ‘oh yeah, I have to slow down to see my VBC patient’. It’s impossible.”

 

“I always equate it [blended payment] to a cross-training sneaker: it’s not good for running, it’s not good for playing tennis. If you want to run, you wear a running shoe, and if you want to play tennis, you wear a tennis shoe.”

 

Both of our experts have experienced the blended payment method first hand, and both have questions about its efficacy as a long-term solution. 

 

“I’ve been in an organization that’s fee-for-service, I’ve been in an organization that is value-based, and I’ve been in an organization that is both at the same time – or trying to be both at the same time – which is kind of crazy,” says Dr. Ramirez. 

 

“It is really hard to do both well,” the CCO agrees. “And I think that’s why some providers don’t necessarily see the value in value-based care – because they just see the documentation requirements and preventative care checklists, and say ‘this is harder medicine’. They’re not looking at the outcomes.”

 

Reaping the benefits

 

Both of our interviewees extol the virtues of working for dedicated value-based care organizations over the blended model. “I love our health center because we’re just a running shoe!” the CCO laughs. “I think certain providers say their VBC programs haven’t been successful because they’re living with one foot in each world.”

 

Dr. Ramirez agrees. “It’s all relative to how you measure the value of VBC,” he tells us. “In my previous stewardship – with a different organization that provided care for senior patients – we were able to improve or extend life by an average five years in seniors with a certain number of conditions. Potentially the costs are higher, but what’s the price of living five more years?”

 

Both parties are realistic regarding the challenge of transitioning to value-based care. “I’m not going to pretend that there aren’t more rigorous documentation requirements in value-based care,” the CCO says. “The documentation is intimidating. And it wasn’t something that providers learned in medical school… If you’re used to commercial documentation, you might be like, ‘this is a burden’.”

 

Accurate documentation starts with education. Clinicians, MAs, coders and other staff must buy into the increased burden of documentation necessitated by the switch to value-based care, before learning the many intricacies of risk adjustment and HCC coding. The DoctusTech HCC coding education app applies active learning theory to engage clinicians at 90%, and encourage lasting behavior change with 75% knowledge retention. It’s the preferred method of HCC education for 9/10 clinicians – ensuring users not only retain the valuable information they’re taught, but that they’re motivated to keep learning for the long term. 

 

If you need help managing the transition to value-based care, get in touch and arrange a demo of the DoctusTech app today.

 

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7 Strategies to improve HCC coding and risk adjustment accuracy

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 in the value-based care healthcare model play a crucial role in ensuring quality care, managing patient populations, and optimizing revenue. Here are 7 strategies to improve HCC coding and risk adjustment accuracy in your VBC organization.

1. Streamlined clinical workflows

Streamlined clinical workflows reduce administrative burdens and free up healthcare providers to focus on patient care. Efficient workflows can also aid in capturing HCC codes more effectively. Organizations should evaluate and optimize their workflows to ensure that providers have the time and resources necessary for accurate coding.

2. Regular coding audits and feedback

Regular coding audits are essential for identifying errors and areas for improvement. They help organizations ensure compliance with coding guidelines and enhance accuracy. Feedback from audits can guide coders and providers in refining their coding practices. These audits can be conducted regularly, and the findings should be used constructively to improve the coding process.

3. Data analysis

Data analysis is an invaluable tool in risk adjustment. By analyzing patient data, organizations can identify gaps in coding and areas for improvement. Data-driven insights can help pinpoint under-documented conditions, ensuring that all relevant HCCs are captured. This analysis also helps organizations gain a deeper understanding of their patient populations.

4. Comprehensive provider education

Healthcare providers are at the frontline of patient care, and their understanding of the importance of accurate HCC coding is paramount. Comprehensive education programs ensure that healthcare professionals are well-informed about the significance of documenting chronic conditions accurately. By equipping providers with the knowledge and tools they need, organizations can improve coding at the source. 

One of the leading HCC coding education providers in this space is DoctusTech. It’s an app that clinicians can use to learn and stay updated about HCC coding. Book a demo to earn how DoctusTech helps healthcare providers train clinicians.

5. Proper documentation training

Training healthcare professionals in the nuances of proper documentation is vital. These training programs help providers understand the specific details required for accurate HCC coding. Coding specialists or educators can play a significant role in delivering this training, ensuring that providers are well-equipped to document patient conditions comprehensively.

6. Advanced EHR and documentation tools

Electronic Health Records (EHRs) have become integral to healthcare documentation. Implementing advanced documentation tools within EHR systems can prompt providers to capture relevant HCCs during patient encounters. These tools can offer real-time suggestions and guidelines, aiding providers in accurate coding.

One of the revolutionary tech solutions for improving HCC code capture is DoctusTech. It makes it easy for clinicians to accurately document HCC codes for every patient within their own EMR. DoctusTech HCC 360 streamlines EMR workflows by combining all external data sources and presenting information to clinicians as they write their progress notes. It can integrate with all major EMRs with minimal hassle. Book a demo here to learn more about this product.

7. Collaboration and communication

Effective communication and collaboration between coders, providers, and administrative staff are vital for HCC coding accuracy. Open channels of communication allow providers to seek clarification or guidance on coding, and coders to provide feedback or request additional information when necessary. This collaborative approach fosters a culture of accuracy and ensures that everyone is working together towards the common goal of improved coding.

In conclusion, accurate HCC coding and risk adjustment are essential for healthcare organizations to deliver quality care while optimizing revenue. These seven strategies – comprehensive provider education, advanced EHR tools, streamlined workflows, regular coding audits, proper documentation training, data analysis, and collaboration – collectively form a robust framework for enhancing coding accuracy. By implementing these strategies, healthcare organizations can meet the challenges of the evolving healthcare landscape while improving patient care and financial outcomes.

As the healthcare industry continues to evolve, following these 7 strategies to improve HCC coding accuracy. By investing in accurate HCC coding and risk adjustment, healthcare organizations can ensure that they are well-prepared to provide the best care to their patients while achieving financial sustainability in an increasingly complex healthcare ecosystem.

To improve your HCC coding accuracy with the DoctusTech app.

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What is the CMS HCC Risk Adjustment Model?

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 Hierarchical Condition Categories, which are groups of medical conditions that share similar expected costs of treatment.

Since its inception in 2004, the CMS HCC Risk Adjustment Model assigns each MA enrolee a risk score based on their demographic information – such as age and gender – their medical conditions, and the severity of those conditions. The risk score is calculated by first assigning HCCs to each enrolee based on their medical diagnoses, then applying a weight to each HCC based on the expected cost of treatment. These weights are then added up to determine the enrolees’ overall risk score.

The CMS HCC Risk Adjustment Model is designed to account for differences in the health status and expected costs of care among MA enrolees, and to ensure that MA plans are adequately compensated for the medical needs of their enrolees. The risk adjustment methodology is used to adjust payments made to MA plans based on the enrolee’s risk score, with higher risk scores resulting in higher payments to the MA plan.

The CMS HCC Risk Adjustment Model is updated annually to reflect changes in the prevalence and costs of medical conditions, as well as changes in the coding and classification systems used to identify medical diagnoses.

What is a RAF score? 

The Risk Adjustment Factor (RAF) score is a measure used to adjust the payment for healthcare services based on the health status and expected medical costs of the patient. The RAF score is typically used in the context of Medicare Advantage (MA) plans, which are a type of health insurance offered by private companies that contract with Medicare to provide Medicare benefits to eligible individuals.

The RAF score is calculated using a formula that takes into account the patient’s demographic information, such as age and gender, as well as their medical conditions and the severity of those conditions. The formula assigns a weight to each medical condition based on its expected cost of treatment. The weights are then added up to determine the patient’s overall RAF score.

So a patient has a RAF of 1.5 may have a 0.6 from demographics, a 0.3 for diabetes, and 0.6 from COPD. 

The RAF score is used to adjust the payment made by Medicare to the MA plan for each patient. Patients with higher RAF scores are considered more expensive to treat, and the MA plan will receive a higher payment to cover the expected costs of care. This helps to ensure that MA plans are adequately compensated for the medical needs of their patients, and that patients with more complex health conditions receive appropriate care.

How do HCCs relate to it?

Each year, Medicare calculates an amount of money that will be paid per member per month (PMPM).  This same base rate is paid out for every patient, regardless of what services were done.  This base rate is then multiplied by the patient’s RAF score so that more money is payed out to take care of patients with a high RAF (sicker patients) than those with a low RAF (healthier patients).  

If a CMS patient has a high RAF, they he/she is expected to get extensive medical care, clinicians who enrol these are reimbursed more than those who have low RAFs. The additional reimbursement amounts for patients who qualify will not be paid to organizations that do not properly or completely document HCC codes as incorrectly documented codes do not add to the RAF score.

To know more about HCC coding and how to improve it, you can refer to our blog on ‘How to improve HCC coding and avoid risks.’

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Why is HCC coding important for medical practices?

‘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. This system is used to calculate a risk score for each MA enrolee, which acts as a measure of their expected healthcare costs based on their medical conditions and demographic information. The risk score is used to adjust payments made to MA plans, with higher risk scores resulting in higher payments. Accurate HCC coding is essential for ensuring that MA plans are adequately compensated for the medical needs of their enrolees, and for providing appropriate care to patients with complex medical conditions. Accurate HCC coding is essential for the success of the value-based care system,  so explore these five key reasons why HCC coding is important for medical practices. 

Accurate risk adjustment

HCC coding is used to calculate a risk score for each patient, based on their health status and expected healthcare costs. This score is used to adjust payments made to healthcare providers, so accurate HCC coding is crucial to ensure that providers are fairly compensated for the care they provide.

Improved quality of care

By accurately identifying and documenting all of a patient’s medical conditions, HCC coding helps to ensure that providers have a complete picture of the patient’s health status. This can help providers deliver more personalized, effective care.

Regulatory compliance

HCC coding is subject to regulatory guidelines and requirements. Accurate and complete HCC coding helps healthcare providers to comply with these regulations and avoid potential penalties or legal issues.

Resource optimization

HCC coding can help healthcare organizations optimize their resources by identifying patients who are at high risk of costly medical events. By targeting these patients with preventive care and disease management programs, healthcare providers can help to reduce healthcare costs and improve patient outcomes.

Increased revenue

Accurate HCC coding can help healthcare providers maximize their revenue by ensuring they receive appropriate payments for the care they provide. By identifying all relevant medical conditions and coding them appropriately, providers can ensure they aren’t underpaid for the services they render.

 

Incorporating HCC coding into a medical practice is essential for documentation accuracy, workflow efficiency, and regulatory compliance. It helps reduce errors and omissions, improve billing and reimbursement rates, and provide more detailed reporting. By incorporating accurate HCC coding, medical practices can ensure they continue to deliver the highest quality of care to their patients.

The DoctusTech app is the easiest, most effective way for clinicians to learn HCC coding – with a 90% clinician engagement rate. The DoctusTech app lets you train whenever and wherever you want, and benchmark yourself against your peers to track learning and performance. 

Book a free demonstration here and start training today.

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How to Improve Risk Adjustment Factor Score Accuracy

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, we’ll look at 10 proven ways to increase your Medicare risk adjustment factor score accuracy. These strategies include optimizing patient care processes, leveraging data-driven insights, investing in technology, and building strong relationships with patients, care teams, and payors. With the right approach, healthcare providers can improve their Medicare risk adjustment factor score accuracy and create more value for their organization.

Optimize Patient Care Processes

To improve your risk adjustment factor score accuracy, start with the basics by optimizing patient care processes. This includes reducing unnecessary tests and procedures, improving adherence to treatment protocols, and managing patient expectations around outcomes. For example, make sure patients follow treatment plans for conditions like diabetes and heart disease. These conditions require ongoing care and self-management. Poorly managed conditions can lead to complications and costly readmissions. Best practices include clearly communicating expectations to patients and providing them with tools and resources to help them manage their condition. This can also help to improve your readmission rates. Hospitals with lower readmission rates have higher risk adjustment factor score accuracy

Leverage Data-Driven Insights

To drive better outcomes, healthcare providers must have a clear understanding of what’s working and what isn’t. Use data to identify areas for improvement and then create action plans to address them. For example, review readmission data to identify the root causes of readmissions. Then use this information to create interventions or best practices to help improve patient outcomes. Find ways to collaborate with other organizations in your area. This can help you gain access to a wider range of data and insights. Find opportunities for partnerships with other healthcare providers. These partnerships can help you gain access to patient information and clinical data that can inform your decision-making and help you improve care.

Invest in Technology

New technologies are transforming how healthcare providers deliver care and how patients manage their health. Investing in these technologies can help healthcare providers improve outcomes and reduce waste. This can also help to improve your risk adjustment factor score accuracy by reducing readmissions and freeing up staff time to spend with patients. Find ways to implement technology throughout the patient journey. Start with areas where it can have the biggest impact. For example, use wearable devices to monitor patient vital signs and provide real-time feedback to care teams. This can help to reduce unnecessary readmissions by providing earlier alerts when patients are showing signs of deterioration. Find creative ways to use technology to improve patient satisfaction. Initiatives like digital check-in and virtual visits can help to reduce wait times, improve patient experiences, and reduce the overall cost of care.

Build Relationships with Patients, Care Teams, and Payers

Strong relationships with patients and care teams can help healthcare organizations achieve better results. This includes improving the relationship between physicians and patients. Relationships are also important with payers. Engage with your payer community and educate them about your clinical performance. Be transparent about your results and work to improve them over time. For example, work with payers to improve billing and coding practices. This can help to reduce your risk adjustment factor score accuracy by improving your Medicare reimbursements. Find ways to better engage patients with chronic conditions. This includes providing patients with tools and resources to help them manage their conditions. It also includes providing them with regular feedback on their progress.

Improve Patient Outcomes

These strategies can help to improve patient outcomes, which will also help to improve your risk adjustment factor score accuracy. For example, help patients adhere to their medication regimens by using effective strategies like regular check-in calls or SMS reminders. Find ways to optimize the use of specialists. This includes diagnostic imaging services and intensive care unit visits. Find ways to reduce patient wait times. This includes reducing the time spent in the emergency department and the time spent in the hospital. It can also include reducing the wait times for physician appointments. Find ways to increase patient safety. Adverse patient events are an important measure of the quality of care. By finding ways to reduce the number of adverse patient events, you can improve your risk adjustment factor score accuracy by as much as 8%.

Use Quality Improvement Tools

Find ways to incorporate quality improvement tools into your operational processes. This can include adopting a standardized process for managing patient care. It can also include adopting a standardized process for measuring and improving patient outcomes. Use tools like the 9 Wards method. This is an evidence-based method for improving patient safety by reducing the number of adverse events. It can be used in any healthcare setting. Find creative ways to use simulation and role-playing exercises to identify and work to improve system-wide issues. This can help to improve communication between different departments and improve the consistency of care across your organization.

Increase Physician Engagement

Strong physician engagement can help improve patient outcomes and clinical outcomes. It can also help to reduce readmissions. For example, make sure physicians are following their patients. This includes timely follow-ups and regular communication with patients after they have left the hospital. Find creative ways to build stronger relationships with physicians by incorporating them into decision-making processes and involving them in your organizational improvement efforts. Find ways to recognize and celebrate physicians for their clinical achievements. This can help to improve physician engagement and boost morale.

 

With the Doctus Tech App, clinicians can greatly improve their risk adjustment factor (RAF) score accuracy. This app provides a comprehensive suite of tools and resources that give clinicians the ability to better manage their patient data for more accurate risk adjustment. By leveraging the features of this app, clinicians can customize their approach to risk adjustment in order to optimize their score and make sure they are adequately reimbursed. Furthermore, this app is designed to be user-friendly and easy to use, making it a great resource for those looking to maximize their RAF score accuracy without having to be familiar with the complexities of risk adjustment processes.

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Risk, Revenue & Care: How HCC coding and RAF impact Value-Based Care Revenue and Patient Outcomes

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 that patient. No matter where the diagnoses and HCC codes originate, RAF scores follow the patient back to the group that has taken on risk for that patient. So if your patient sees a cardiologist and is diagnosed with afib, that will impact your capitated reimbursement from CMS. And that will also impact the care required to keep that patient healthy and out of avoidable hospitalizations.

 

Although there are 80+ HCC codes, Medicare has created 8 special groups of HCCs with similar diagnoses of differing severity: cancer, diabetes, COPD, renal disease, substance use disorder, cardiorespiratory failure, psychiatric disorders and pressure ulcers. HCC codes that belong to one of these groups may be overridden by a different HCC in the same group higher up the hierarchy.

 

For example HCCs 8-12 all involve cancer, from solid breast tumors to leukemia. If a patient has a cancer in HCC 8 and a cancer from HCC 11, the more serious category (HCC 8) will be the only one that is reimbursed. Also worth noting, lower numbered HCCs trump higher numbers in their group, and have a greater impact on RAF scores.

 

Medical complexity diagnosed & documented determines Reimbursement

CMS uses RAF scores to render capitated payments

 

As illustrated above, HCCs contribute to RAF through a somewhat complex relationship, but the key is accurate documentation of all patient conditions and treating the patient for the complexity that has been diagnosed. Each patient has a RAF score that typically falls within the range of 0.6 to 1.2. When looking at a risk contract, CMS reimburses for each patient according to their RAF score, adjusted for age, sex and regionally based on costs of care.

 

So the overall average RAF within a contract determines the overall reimbursement for that population. The payments are termed capitated (from the Latin word for head) as it is paid “per head” rather than per-action, or CPT codes submitted in a FFS arrangement. Often, revenue is looked at in a per-member per-month average (PMPM), where the total population RAF and the total PMPM capitated payments are reviewed to determine how well a contract aligns with regional averages, numbers per clinic, or per doctor’s panel.

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Value-Based Care Revenue and Outcomes: Impact of HCC Coding and RAF

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. 

 

Diagnosing for medical complexity

Physician diagnoses patients with all medical conditions.

 

One shift when transitioning to Value-Based Care is the need to diagnose very specifically for complexity, rather than simply diagnosing a disease. In the old Fee-For-Service (FFS) model, it would be reasonable to diagnose simply diabetes mellitus. In a VBC model, it would serve the patient better to diagnose with a high degree of specificity—type 2 diabetes mellitus with neuropathy—to fully capture the complexity and severity of the disease, ensuring that all conditions are documented and the plan of care is executed accordingly. 

 

“Medical complexity” is another way to say “How hard is it going to be to keep this patient out of the hospital?”

 

For patients with very mild chronic conditions, it is often easier to manage their symptoms, keep them on their meds, and keep them healthy; thus, not requiring intensive medical resources. Comparatively, patients with very complex diseases can be very resource-intensive, and require a great deal of time, attention, services, and oversight to manage their chronic conditions and maintain their health. Therefore, these patients with more complex disease states are reimbursed at a higher rate, to allow for more intense and expensive care.

 

 

Documenting with ICD-10 Codes

Diagnoses are documented with the appropriate ICD-10 codes

 

ICD-10 codes are still the backbone of medical diagnoses, and typically the only codes used in a VBC arrangement. So the diagnosis coding that was learned in FFS arrangements is still at play, just with a slightly different focus – especially, when diagnosing chronic conditions.

 

Hierarchical Condition Categories are a subset of ICD-10 codes, therefore not all ICD-10 codes map to HCC codes. Each risk-adjusting diagnosis will alter the patient’s risk profile, with the more serious conditions increasing RAF score more than less serious. But some HCCs supersede others when they are within the same category. For example, E11.9 – diabetes without complication will add 0.11 to the patient’s risk score, but E11.22 – diabetes with chronic kidney disease will add 0.33. As the codes are hierarchical by category, the highest diabetes score will be the one passed along to the patient’s total RAF – not both. 

 

Risk follows the patient, not the provider

The risk score of a patient is tied to the patient themselves, not the provider. Diagnoses submitted to medicare by any clinician anywhere will add to the patient’s risk profile. Each patient has just one PCP assigned to them when they join a managed care plan, and that PCP will receive payment for that patient’s care, as they are the one taking on risk. 

 

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How HCC coding and RAF impact Value-Based Care Revenue

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 codes relate to patient care? Do HCC codes help patients, or is coding just to generate revenue? How do you avoid under-coding, or over-coding, and harden your charts for an audit? What is the role of the clinician, when there are also coders? How do you educate clinicians on HCC coding, when they barely engage in the seminars? How should clinicians view HCC coding and RAF scores as a component of patient care? 

 

There are a lot of questions. So in this series of blogs, we are going to lay out a robust and thorough explanation of each piece of the VBC puzzle, share how they relate and impact each other, and by the end, you will have a thorough understanding of both the VBC space and your role in it. 

 

First, a word about risk. Upside risk, downside risk, two-sided risk, quality scores, stars… there are only really a few things you need to know about risk.

In Value-Based Care, when you take on risk for a patient population you are making a wager. 

 

Your organization wagers that they can both run a business and keep a patient population healthy for a predetermined dollar amount, set by CMS. If you are caring for a very sick patient population, you will need more resources. And the wager is that your organization can provide effective care within the budget. This incentivizes a care team to keep patients healthy, rather than only treating them when they get very sick. 

 

The organization that takes on risk is reimbursed in a capitated payment model, paid per-member, per-month (PMPM), based on the Risk Adjustment Factor (RAF) of your patient population the year before. That score is the sum of all RAF scores from the patients in your VBC contract. The RAF score of each patient is the sum of all the diagnosed chronic conditions, documented with Hierarchical Condition Category codes (HCC codes) that risk adjust. CMS payment models typically pay for conditions diagnosed the previous year.

 

Over the next few weeks, we are going to dig deeper into four central concepts in Value-Based Care, with special attention paid to how each piece impacts patient care. 

 

– Diagnosing for risk in VBC

– The basics of RAF and how it is calculated. 

– How RAF and Revenue drive Patient Care and Innovation

– RAF, Revenue, Audits and the DOJ

 

To our VBC clinicians, thank you for the work you’re doing to move patient outcomes to the forefront of healthcare. Thank you for truly caring for your patients – and for your patients with all the required learning, coding and documentation. It matters, you matter, and your healthy patients will thank you.

 

To our VBC admins, operators and physician executives, your management of all the moving parts and pieces is critical to achieving the pivotal shift from fee-for service to a value-based model. Thank you for your commitment to patient-centric care and clinician satisfaction. Without you at the helm, the system would never change. 

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What Is HCC Coding?

Back in 2004, CMS introduced HCC coding as a tool to help estimate Medicare costs. Today, HCC coding us used across Medicare Advantage plans, the Medicare Shared Savings Program, Medicaid, and private health plans – all deploying a variation of the risk adjustment model in order to quantify the upcoming cost of care for their member population, and as a mechanism of submitting that care need to CMS for payment. And yet, the question comes up more often than you may think: “What is HCC Coding?”

 

Even in the value-based care space, there is confusion around HCC coding, which ICD10 codes risk adjust, and how to diagnose and document accurately and specifically. So if you’re moving from fee-for-service into VBC, taking on risk for the first time, or a veteran at HCC coding for VBC, this article will clarify much of the confusion and simplify what HCC coding is, why it matters, how it is used and what the future holds for HCC and VBC.

 

Do Doctors Know HCC Coding?

First, clinicians typically have a good working knowledge of ICD-10 codes. And every org has their lookup functions baked into the EMR. However, not only do most ICD-10 codes not work as HCC codes, many of the traditional ways of diagnosing in the fee-for-service world are turned on their heads in VBC. So knowing or having access to ICD-10 codes is not actually that much of an advantage when learning HCC coding. In fact, in some cases, that knowledge can be a liability. 

 

Knowing the code to document diabetes is great, but using that same basic E11.9 that you’re used to is not helpful when diagnosing in a risk model. You need to dig into the complications, the severity of the disease state, and both diagnose and document with high specificity in order to treat and afford to treat the full complications of the disease. If you under-diagnose, you will likely under-treat, and risk an avoidable hospitalization, the risks to the patient and the costs notwithstanding. So in the case of diabetes, a quick check of the toes could yield a missed diagnosis that is critical to the patient’s care as well as accurate RAF and adequate capitation.

 

What are HCC Codes?

Hierarchical Condition Categories – as the name implies, the categories relate to a hierarchy of of conditions, and it all works together as an efficient sort function to calculate the risk that the patient’s will be expensive. Think about it like this: A patient with mild diabetes as unlikely to end up in the ER due to their disease, so basic diabetes does not risk adjust; whereas a patient with severe diabetes with complex circulatory symptoms that have already led to amputation of one toe is at extremely high risk of ending up in the ER, and they will require a lot of personal and intense care to keep them out of the hospital. And care costs money, so risk and care are nearly synonymous. A higher risk diagnosis gets an HCC code with a higher risk adjustment score, which adds a higher multiplier to the capitation of that patient – meaning the government pays more dollars a month to maintain that disease and help that patient stay out of the hospital.

 

How do clinicians use HCC coding? 

The primary use of HCC codes is to document new chronic condition diagnoses, and recapture chronic conditions being treated, and communicate those diagnoses to Payors and CMS in order to receive capitated payments.

 

How do HCC codes translate to revenue?

The payment model is obviously vastly different from the traditional fee-for-service (FFS) format where actions are performed, justified, transmitted as CPC codes and reimbursed by payors and/or CMS. In the VBC model, a patient is diagnosed with a specific chronic condition, that condition is documented and coded based on hierarchical condition categories that adjust the risk associated with keeping that patient healthy and out of the hospital. By taking on that risk, the plan or provider group is agreeing that, if given a reasonable amount of money, they will be able to maintain the health of that patient. That money directly ties back to the HCC codes documented, and is paid on a capitated model, with a certain dollar amount paid per-member per-month (PMPM). Those payments allow the overall organization to provide excellent care to the entire patient population, paying extra attention to those whose disease states have reached a complexity where significant resources are required to maintain optimal health. Whether for-profit or non-profit, the organization providing care will financially benefit from accurate diagnosis coding and aggressively proactive care. 

 

How does HCC coding help doctors get paid?

When done correctly, practicing medicine in a Value-Based Care arrangement means more time for doctors, less administrative burden, less burnout and more time to spend per-patient. Smaller panels, and more help treating patients mean that a good doctor can provide truly life-changing care to patients without over-working or over-coding. And by practicing good medicine with proper HCC documentation, you will find your organization flourishing and your patient outcomes improving – all while actually decreasing the overall cost of healthcare. Sure, there is no such thing as a perfect system, but this is as close as we can get in today’s environment. And with an eye to continuous improvement, good coding and good care puts your organization squarely on the path.

 

How does HCC coding translate to patient care?

You cannot treat what you do not diagnose. And if you diagnose with an eye to changing the trajectory of the patient’s care plan, you are practicing good medicine. To diagnose without proper documentation denies the patient the care that comes from critical revenue. And to document without care is, simply put, fraud. So diagnose with high specificity and proper documentation to ensure that your clinic can afford to provide the kind and quantity of care that will keep your VBC patients out of the hospital. Better HCC coding = better care.

 

How long does it take to learn HCC coding?

Depending on the tools used for teaching and learning, it can be a years-long process fraught with frustration and difficulty – OR – it can be a simple weekly check-in on an app that uses modern learning methodologies to make mastery quick and easy.

 

 

How does HCC coding relate to compliance audits?

The number of compliance audits of provider groups has been steadily rising. The DOJ launches new lawsuits against both large payors and smaller provider groups with increasing penalties. And the Supreme Court has refused to step in and ease the pressure, letting whistle-blower cases proceed unchecked. Clinicians are doing their best, but that is no defense in an audit – the only thing that matters is facts, documentation, accuracy and pure compliance.  

 

Practicing healthcare is an art, but documenting is a strict science, and anything less than accurate documentation vigorously maintained will likely result in negative audit outcomes and your group’s name landing in next month’s headlines.

 

CMS and DOJ have been increasingly scrutinizing payor strategies and billing patterns as it pertains to Hierarchical Condition Categories (HCCs). As more and more physician groups take on risk in the VBC models, it is imperative that physician groups do not make the same mistakes as their payor partners (intentionally or not). 

 

Some of the most common offenses are fairly simple to avoid. But as we all know, simple does not mean easy. In fact, achieving simplicity can be far more difficult than creating complexity – which is what happens most of the time. A simple solution requires tremendous discipline. 

 

HCC coding for acute conditions

As a rule of thumb, an acute code should not repeat 2 years in a row for a specific patient. And usually, even the first year is inaccurate. Acute heart attack is one of the most common errors penalized by CMS and the DOJ. One reason for this is misunderstanding how to document “history of heart attack” vs “heart attack.” Another version is chronic conditions that have been mis-coded as acute. There is a very short distance between upcoding and practicing good medicine. 

 

It is sometimes appropriate to use these within the year where the acute event occurred, but the following year you must diagnose and document a different code. A third of the most common acute condition dinged by CMS is the combination of #1 & #2 – Acute Stroke and Acute Heart Attack. 

 

Lack of clinical accuracy or supporting documentation – Medical diagnoses are complex and sometimes exist in the gray area between possibilities – but coding and compliance are hard rules. Picking the wrong code. Commonly misused diagnoses. While RADV audits are routinely looking for MEAT criteria, they’re not looking for clinical criteria or diagnostic accuracy. 

 

Commonly misrepresented diagnoses: The exact criteria can be confusing even though the treatment can be the same for mild, moderate, and severe forms of certain diseases. Misrepresentation of the severity can result in overpayment from CMS, and legal and financial penalties – not to mention the obvious ethical concerns. 

 

What is HCC Coding Without Plan of Care?

Now that a doctor has diagnosed a chronic condition, what is the plan to treat or manage the disease? A diagnosis that does not demonstrate a direct and deliberate impact on the plan of care is almost always incorrect at best, and in an audit, illegal. Diagnosing and documenting should function as a mechanism of providing care; documenting to document is never correct. So be on the lookout for conditions diagnosed and codes submitted that do not impact the plan of care. These are often targeted by CMS, both in OIG compliance audits and RADV audits.

 

How is HCC Coding improved by Education and 1-on-1 coaching?

Build a culture that connects patient care to diagnostic specificity and accuracy in coding and documentation. No doctor wants the business managers coming down from their offices, clipboard in hand, scolding about how code capture and RAF scores impact revenue. But every clinician understands the need to improve care and decrease cost. So start there – in VBC, practicing good medicine and providing better care starts at accurate diagnosis right through to rigorous documentation. 

 

Documentation enables treatment, funds resources to provide care, ensures better health outcomes for patients and actually lessens clinician workload – when done correctly. Chart audits do not have to be brutal, they can be helpful, asking clinicians how a particular diagnosis changes the care trajectory, and helping document for maximum patient benefit. Internal meetings should focus on coding as care. And manual chart reviews should be performed by medical doctors to give timely 1-to-1 feedback. If this is done, the last error on the OIG’s list of usual suspects will go down:

 

How does HCC coding impact clinician workload? 

It can go either way – with increased coding requirements becoming a burden, both to learn in boring seminars and to chase down in chart reviews. But with modern advanced app-based learning tools like DoctusTech, clinicians can master HCC coding in as little time as 5 minutes per week. 

 

What is HCC coding to the OIG?

The Office of Inspector General of the Department of Health and Human Services is at the forefront of auditing healthcare fraud, and recommending action from the DOJ. 

 

From OIG: Since its 1976 establishment, the Office of Inspector General (OIG) has been at the forefront of the Nation’s efforts to fight waste, fraud and abuse and to improving the efficiency of Medicare, Medicaid and more than 100 other Department of Health & Human Services (HHS) programs.

 

In today’s healthcare landscape, the OIG is finding value-based care to be a target-rich environment, with special focus placed on Medicare Advantage programs, as these allow a small action (documenting a chronic condition that does not actually exist) to multiply into a year of capitated payments to an organization. The simple act of up-coding a condition into something more complex than it should be or over-coding by documenting a chronic condition that does not exist results in thousands of dollars per year in fraudulent overpayments. 

 

What is HCC coding to the DOJ?

While the Department of Justice is not directly concerned with healthcare, they are very concerned about medical fraud, which defrauds the government’s medicare programs, and in extension, the American people. Most often, the DOJ takes on whistleblower cases, where an individual from inside an organization shares insider information regarding acts of upcoding or overcoding that are both large and systemic. These whistleblowers stand to profit significant sums, at times earning up to 20% of the total settlement. And with the recent Sutter case settling at $90,000,000, the whistleblower could potentially take home $18 Million. The False Claims Act ensures that the federal government has a means of penalizing organizations and individuals who, through filing false claims, defraud the government. While this law has been in place since the 1800s, it is getting renewed attention as the DOJ discovers millions of dollars in false claims specifically in Medicare Advantage programs, as these allow an organization to bill CMS with very little scrutiny or oversight. 

 

Top mis-used HCC codes

We address this in a report, feel free to request it HERE.

Also, codes most found in unlinked chart reviews, and subject to RADV audits are detailed in our white paper, found HERE.

 

What are the requirements for HCC coding documentation? 

Generally referred to as the MEAT Criteria, here are the four things you must have to document an chronic condition with an HCC code:

M = Monitoring by ordering or referencing labs, imaging studies or other tests

E = Evaluation with a targeted part of the physical examination specific to a certain diagnosis 

A = Assessment of the status, progression or severity of the diagnosis 

T = Treatment with medication, surgery, lifestyle modification, or referral to a specialist.

 

What are the best HCC coding tools?

What apps are available for learning, search, lookup, documentation? This may be a bit of a self-promoting softball, but if you haven’t checked out the DoctusTech app by now, you really should. Make time with a member of our team to see if the DT app is right for your team. Demo DoctusTech today.

 

What is the best way to change physician behavior around HCC coding 

Notes and insights from a study published by AJMC on how to change physician behavior. “The authors evaluated methods for implementing clinical research and guidelines, in order to change physician practice patterns, in surgical and general practice. They evaluated the effectiveness of different implementation methods.”

 

And as we have demonstrated through successful behavior change in physicians using our HCC coding education app, the most common solutions aren’t the most effective when it comes to ongoing positive change in physician behavior. Want to learn how to change physician behavior? Let’s dig a little deeper into a review of reviews, revealing some hard truths.

 

We’ve been saying for years, lectures do not work. Emails do not work. If you want to know how to change physician behavior on HCC coding, don’t take our word for it. The American Journal of Managed Care released a systematic review evaluating fourteen medical reviews in an effort to understand which interventions are most effective in changing physician behavior for the better and improving patient outcomes. 

 

It is evident from their publication that the methods of intervention most commonly deployed in teaching doctors HCC coding are rarely able to create lasting change in physician behavior. 

 

What is the best tool inside the EMR?

The DoctusTech Patient Data Analysis Platform (PDAP) is the premier tool for Value-Based Care, living inside the EMR and helping clinicians find and use the best HCC codes, track and manage care associated with chronic diagnoses, and learn which codes to use for which patients – all while reducing clinician workload. It helps readdress conditions diagnosed last year, significantly improving recapture rates. And it helps administrators see into the data by clinician, patient, clinic or by codes. Learn how the DoctusTech PDAP can help your patients and your doctors live happier, healthier lives. Demo DoctusTech today.

 

 

 

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Health Systems Set Sights on Risk-Based Payment in Medicare Advantage

Nearly 60 percent of health systems are looking to move into risk-based Medicare Advantage programmes in the coming year, according to the Healthcare Financial Management Association (HFMA) executive survey for Guidehouse Health Insights. This is a 14 percent increase from the June 2019 Guidehouse/HFMA analysis, Guidehouse said.

 

According to the survey of over 100 CFOs and finance and managed care executives from provider organizations, Medicare Advantage isn’t the only line of business that will take on risk in 2022.

 

More than half of executives (52% ) plan to increase risk-based payment or capitation in their commercial lines of business, while 49% anticipate taking on more risk or capitation through Medicare alternative payment models. In other words, health systems expect risk-based payment to both increase and diversify across business lines.

 

More than one-third of executives believe that risk-based payments will increase in managed Medicaid, 33 percent in direct-to-employer arrangements, and 12 percent “otherwise.”

 

According to Guidehouse Partner Richard Bajner, we are seeing increased interest from providers to own the premium dollar through risk-based arrangements. Large payers, on the other hand, have been investing directly in primary care assets to gain control over the flow of care and better manage services delivered to members, increasing the need for payors and providers to collaborate closely on market strategies, according to the press release.

 

According to Guidehouse, payviders, the value-based partnership between a payers and provider, can employ risk-based contracting between payors and providers, provider-sponsored health plans, joint ventures, and payor-new-entrant partnerships to encourage the adoption of employer-sponsored health plans.

 

Payvider models, however, are not suitable for all markets, the study found. Furthermore, a recent survey discovered that health systems faced substantial challenges in establishing strategic partnerships with payors, a crucial element of payvider success.

 

According to the survey, 50% of executives cited pursuing payor models or increased risk, capitation, or joint venture arrangements as their top external challenge. This challenge was chosen over local competition (21%), legal/trust issues with payors (10%), other (9%), new entrants/disruptors (6%), and price transparency compliance (4%).

 

Despite the challenges with fee-for-service, risk-based revenue has stalled.

 

In addition, 52 percent of executives said that vertically integrated health plans, such as UnitedHealth Group, were a major barrier to success with pay-for-performance models in their market.

 

According to the survey, 36% of executives see data and technology costs, integrity, reporting, and insights as their greatest internal hurdle to pursuing payvider models or increasing risk, capitation, or joint venture arrangements. Internally, health systems are having trouble with data and technology.

 

23 percent of those surveyed cited lack of collaborative payor/provider partners as the biggest challenge to achieving quality or cost outcomes, while 13 percent said scale, 10 percent said difficulty achieving quality or cost outcomes, and 9 percent said leadership alignment or support was the most challenging aspect (Klaphake, 2018).

Despite taking a risk-based payment approach, most health systems are still developing the required capabilities in-house. Thirty percent of executives said their organisation is collaborating with a health plan, 21 percent are outsourcing capabilities, and 7 percent are sourcing capabilities from other healthcare organisations. Around half (51 percent) believe the abilities are being developed in-house.

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DoctusTech Helps: Change Clinician Behaviour

According to the American Journal of Managed Care (AJMC), the least effective method for continuing medical education (CME) for clinicians is distributing printed materials: emails, PDFs, flyers, email blasts, and so on. Many medical professionals believe that clinician education should be concerned with encouraging continuous development rather than simply raising consciousness. What, then, are the most effective strategies for accomplishing the goal of both informing and changing clinician behavior?

 

The AJMC says that the methods of intervention most commonly deployed in teaching doctors HCC coding are those same methods determined to rarely create lasting change in physician behavior (classroom lectures, emails, PDFs, flyers, email blasts). So most frequently utilized modes of learning are clearly out.

 

“When you’re seeing patients, you remember the questions, and you remember what you need to ask the patients.” – Dr.  Villaplana-Canals, Florida, DoctusTech App User

 

Both the AJMC and common sense agree  that active education methods and multifaceted interventions are the most effective when it comes to educating and changing physician behavior. The DoctusTech mobile app provides active education and multifaceted interventions through clinical vignettes. In other words, our app helps you achieve your desired outcomes – as a physician, or as an operator for your physicians. In fact, we provide the most effective intervention methods, demonstrated by consistently better outcomes.

 

How?

 

Learning in the app is driven by clinical vignettes, placing clinicians in a real-life patient scenario, presented with symptoms and facts, and then asked questions about diagnosis and documentation, all in an effort to alter the method of diagnosing from the fee-for-service approach most physicians were educated in to a value-based care system, in which chronic conditions are diagnosed in a very specific manner, with an eye to risk and outcomes. By including any and all information about the diagnosis that impacts risk adjustment in the diagnosis, clinicians learn to both diagnose and document those diagnoses with supporting information in the chart.

 

“The mobile app is wonderful, in that it’s a clinical vignette – it’s what is literally in front of their face, and it gets them thinking.” – Teresa, Director of Clinical Documentation Improvement

 

For clinicians, behavior change is accomplished through learning in clinical vignettes with the DoctusTech mobile app. Doctors learn more deeply and permanently about diagnostic procedures and proper documentation by sitting through a clinical vignette. The socratic method is a highly regarded teaching tool as well as being one of the most commonly used teaching strategies in medical school. The socratic approach is utilised by medical students as they learn by questioning in clinical vignettes. It is fitting, therefore, that they will gain a new store of knowledge through clinical vignettes.

 

“It does reinforce for us something that, although most doctors use a problem list, most of the problem lists … ended up being too long, too nonspecific, and very unwieldy to use in the clinic. The training taught me to make sure you have the linkages and causations clearly laid out.” – Dr Joseph Bateman, Medical Director, Christ Hospital, DoctusTech App User

 

Clinicians can justify the RAF score impact of those diagnoses by supporting them with appropriate documentation that meets the MEET criteria. When there is an audit (When, not If), their charts are proper and in order, and their patients are well cared for.

 

Rather than diagnosing “diabetes” a DoctusTech educated physician would instead test for complications and diagnose a specific disease condition, accurately reflecting the capitated payments for that person’s care. The behaviour change comes from switching from one ICD-10 code that doesn’t risk adjust to a more specific diagnosis, using a different ICD-10 code that does adjust the risk of that patient and accurately reflects the change in capitated payments for their care.

 

Book a demo today, and experience DoctusTech Mobile App’s transformative teaching techniques for yourself!

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DoctusTech Helps: Decrease Clinician Workload

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 the disease. Now, some of those burdens have certainly eased over the past 10 months – but the prevailing concern of burnout from overwork has hardly abated.

Burnout is a widespread problem in any industry, but the stakes are even higher in healthcare with lives of patients on the line. Quality and safety of care is our top priority and errors or lack of awareness can lead to terrible consequences.

With burnout on the rise and VBC/HCC knowledge requirements continuing to grow, it can feel like there is an impossible riptide in front of today’s clinicians. And with healthcare relentlessly marching in the direction of Value-Based Care, it’s no wonder why new clinicians have a difficult time onboarding. Requiring providers to add HCC coding to their already complex workflow is not only vital to improve the industry, it is increasingly mandated by CMS.

The DoctusTech HCC Coding App is designed with a sole purpose in mind: to reduce clinician workload, and make it easier for them to diagnose, and ultimately, take care of their patients.

The Socratic method, clinical vignettes, and question and answer sessions are the most effective methods for capturing long-term knowledge. This is how doctors were taught in the first place, and this is the best way to do it. With DoctusTech, they can learn HCC coding in the same manner—from other doctors using clinical vignettes—on their own time, requiring only an average of five minutes per week.

The DoctusTech Mobile App is based on our successful HCC education and retention strategy, which relies on clinical vignettes customized to the clinicians’ weaknesses and strengths, which are sent to their mobile phones every week. With an engagement rate of 90%, DoctusTech App results far exceed any other learning tool, technology, or strategy.

After using the app for HCC coding education, clinician RAF accuracy is consistently increased based on the learning data.

What methods does the app use to accomplish this?

Our app gamifies the learning experience, connects clinicians with one another, allows them to compete for real prizes, and provides administrative support. In addition, the most advanced HCC code search tool in the world is available. Clinicians earn 25 CME hours every year as they learn HCC coding in a non-boring app!

If HCC Coding and Physician Burnout are at all on your radar, we’d love to share a solution to both. Better solutions are out there – and they outperform seminars and code-of-the-month email blasts for engagement and results. And they free up your coaches to focus on the 20% that need it the most.

To learn more, book a conversation with our team!

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DoctusTech Helps: Increase RAF Accuracy

“I don’t care if the RAF goes up or down, I only care if it’s accurate.”

Dr. Farshid Kazi, Co-Founder, DoctusTech

 

If an organization is caught over-coding, up-coing, diagnosing conditions that either do not exist or are not supported in the chart, the cost of these errors can be very high. Audits are no longer just for health plans, provider groups like Sutter, Kaiser (and many others) have also been audited by the DOJ and hit with heavy fines.

 

On the other side of the board are many plans and provider groups that are struggling to diagnose and accurately document chronic conditions that truly do exist and risk adjust, leading to poor performance in VBC contracts and clinician burn-out. 

 

RAF accuracy is achieved through a perfect balance of accurate diagnosis and accurate documentation. 

What is Risk Adjustment Factor Scoring

Risk adjustment factors are used to estimate the expected outcome for a patient based on a number of different factors. One important factor is the patient’s age; other factors include socioeconomic status and comorbidities such as chronic illnesses or conditions. Each of these can be scored to give a single risk adjustment factor score. 

 

DoctusTech Enables 30% Rise in RAF Accuracy

How?

We teach clinicians how to think about chronic conditions, improve diagnosis at the point of care, and help documentation and HCC coding – all in a lovable mobile app. And not only do clinicians learn how and what to code, the app is also the most powerful HCC code finder in the palm of your hand. Look up the code through a variety of intuitive queries, by tests that might indicate a diagnosis, and by related conditions – complete with complexities and branch-points to help drill down into greater specificity. 

 

While we cannot share sensitive client data, we can confidently state that a 30% increase in RAF accuracy is well within the normal range for our clients. 

 

DoctusTech Helps by Boosting Clinician Knowledge and Changing Behavior Just by Engaging With a Lovable Mobile App

The app uses the classic learning technique we all grew to know and love in med school: the Socratic method. By posing questions within a clinical vignette, clinicians learn—and remember—how to diagnose, code and document for risk adjustment. By increasing the fund of knowledge around diagnosing chronic conditions, the app improves unique code capture and documentation, boosting RAF accuracy over a very short period of time. After the initial self-assessment, clinicians are only asked to spend about five minutes per week engaged on the app, and behavior change outpaces traditional HCC teaching techniques by a significant margin. 

 

 

DoctusTech HCC Integrated Platform

 

Instead of clinicians having to go to various external data sources to gather information, DoctusTech’s HCC integrated platform, HCC 360, consolidates all data sources and presents them to clinicians while they are writing progress notes. Here’s how you can achieve greater RAF accuracy with DoctusTech:

 

Improve Patient Visits: Based on your patient’s chart, get real-time prompts for questions to ask or labs to consider.

 

Automate Chart Review: Translate your patient’s chart into HCC code using our A.I. in seconds, based on evidence-based medicine.

 

Faster Progress Notes: You won’t have to wade through third party portals or paper suspect codes anymore; we bring all sources into your EMR to simplify your life.

 

As healthcare continues to evolve, it is crucial that providers get educated and improve their skills in using HCC codes. DoctusTech is a revolutionary new way to improve the accuracy of HCC coding by making sure you know exactly how to code each condition. Our simple mobile app that engages clinicians in an easy guided learning experience while they file HCC coding notes. After only five minutes of training, clinicians can quickly and accurately code their own charts and boost the accuracy of their efforts.

 

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Amazon Announces Plans to Buy OneMedical

Amazon has announced plans to buy OneMedical for $3B. OneMedical is a brick and mortar plus digital healthcare marketplace that operates in several major U.S. markets. The acquisition is Amazon’s latest move in the healthcare sector, and analysts say it could be a sign of bigger things to come. This is not Amazon’s first foray into the healthcare market, but after the Haven experiment closed down, the company has kept a relatively low profile while it tests new business models. In June, Amazon was among several investors that participated in a $35 million funding round for Zscaler, an Austin-based cybersecurity firm that offers an edge security service for cloud networks and internet-facing applications and services. A few months earlier in March, news broke that Amazon had hired former pharmaceutical executive Bernard Jegou as its new vice president of e-commerce strategy and new business development. 

 

And in a very public failure back in 2017, Amazon partnered with Berkshire Hathaway and JPMorgan Chase to form an independent healthcare company called Haven, which it quietly scuttled mid-pandemic, February, 2021. Read on to learn more about how this acquisition could indicate continued interest from Amazon in the healthcare space — or if it is just another pivot from one of its many subsidiaries.

 

 

What is OneMedical?

OneMedical is a primary care practice and digital healthcare marketplace that uses technology to reduce healthcare costs and increase convenience for patients. The company has built a network of more than 500,000 doctors and has partnered with health insurance providers across the country to serve more than 3 million members. OneMedical offers a range of services, including access to an online portal for patients and a concierge service for their members. OneMedical’s network of doctors comes from a variety of specialties, including general practice, pediatrics, OB/GYN, and family medicine. OneMedical also offers telemedicine services, including video visits with doctor consultations and prescription refills.

 

 

Why might Amazon be buying OneMedical?

While Amazon has not released any details about why it is acquiring OneMedical, analysts say this acquisition may be a sign that the company has larger ambitions in the healthcare sector. Amazon has a track record of acquiring companies in sectors where it sees potential for disruption and then gradually building out its business there. This could be a way for Amazon to expand its e-commerce business into health insurance. It could also be a sign that Amazon wants to become a one-stop shop for healthcare services. Amazon has been experimenting with new business models in the healthcare space for several years now. The partnership with Berkshire Hathaway and JPMorgan Chase formed an independent health company called Haven began with promise, but was quietly closed a few short years later. And in June, news broke that Amazon had participated in a $35 million funding round for Zscaler, an Austin-based cybersecurity firm whose edge security service could help internet-facing applications and services like those that run on Amazon’s AWS platform.

 

 

Possible reasons for the acquisition

Analysts say there are a few reasons why Amazon might be interested in acquiring OneMedical. Amazon may be looking to expand its reach into healthcare marketplaces beyond its partnership with Berkshire Hathaway and JPMorgan Chase to form an independent health company called Haven. Acquiring OneMedical could give Amazon a foothold in the digital healthcare space, which has been growing rapidly. Amazon could also be interested in OneMedical’s digital platform for its members. Having an online presence and digital tools for patients and doctors could let Amazon expand into other healthcare sectors, including pharmacy. And Amazon might be interested in the data that OneMedical has on its members, which could be useful for the company’s future endeavors in the healthcare space.

 

 

Amazon has bigger plans in healthcare

Analysts say the acquisition of OneMedical could signal Amazon’s intent to become a major player in the healthcare space. It is unclear exactly what the company’s strategy will be, but it is likely that Amazon will focus on improving the customer experience across the healthcare sector. Amazon is no stranger to industries with high-barrier-to-entry business models. The company has made inroads in industries such as grocery and e-commerce, as well as more traditional businesses such as manufacturing and cloud computing. Amazon has long been a disruptive force in the retail sector. The company has reshaped consumer expectations of online shopping and shifted the entire retail landscape in its wake. The company’s foray into digital and bricks-and-mortar retail has been a boon for customers, and it has also provided a boost for shareholders: Amazon’s stock is up almost 102% over the past year.

Value-Based Care and Risk Adjustment

Experts say that Amazon’s involvement may help OneMedical’s risk management as the adoption of more value-based care programmes continues. Most of One Medical’s business has traditionally been generated from charging commercially insured patients per-visit fees, but since the acquisition of Iora last year, Medicare patients are now served, and revenue is captured as a result of savings through risk contracts. According to their website, OneMedical serves scores of Medicare Advantage plans, though patient numbers were not readily available. Scaling value-based care is challenging for providers without extensive data experience. Those in primary care, retail health, and telehealth should be concerned, experts say.

 

 

The big question: Is this a pivot or a sign of future intent?

Analysts say Amazon’s acquisition of OneMedical may be a sign that the company is pivoting from its health technology investments, like Zscaler, and looking to establish a more direct presence in the healthcare sector. But it is  also possible that Amazon has more ambitious plans in the healthcare space that the acquisition of OneMedical is only the first step in. Whatever Amazon’s end goal is in the healthcare sector, it seems likely that the company will take a slow and methodical approach to growing its business. After all, Amazon has plenty of experience building new businesses from the ground up, and it has a track record of entering new sectors and disrupting existing players with a more customer-friendly approach.

DoctusTech Helps Clinicians Learn HCC CodingPosted on

DoctusTech Helps Clinicians Learn HCC Coding

DoctusTech Helps Clinicians Learn HCC Coding

DoctusTech helps clinicians learn HCC coding through clinical vignettes in an app that is fun and engaging. Diagnosing with the appropriate HCC code is a critical skill for modern clinicians who care for patients in a value-based care arrangement. You cannot treat what you do not accurately diagnose, and you cannot afford to treat what you do not appropriately code. Without the correct diagnoses and accurate documentation and coding, caring for patients with complex disease will be unsuccessful, leading to increased avoidable hospitalizations and increased cost to the organization. 

 

And without a tool to get clinicians quickly up to speed on diagnosing for risk at the point of care, coding accurately and documenting correctly, you will be stuck. Stuck in boring seminars that rarely affect lasting behavior change; stuck with missed diagnoses and missed revenue targets; stuck with patients missing out on essential care; stuck with overworked clinicians; stuck. 

 

How do clinicians learn HCC coding?

This is where DoctusTech Helps. We provide a modern learning tool for the modern clinician, using gamification, competition, real prizes and administrative oversight to see who is engaging and who needs a little extra help. Also, our app deploys all the subtle nudges and complete with the most advanced HCC code search tool on earth.

 

And clinicians earn 25 hours of CME per year, while they learn HCC coding in a non-boring app!

 

In SCUBA diving, the diver must add just the right amount of weight to maintain perfect positive buoyancy; too much and you will sink, too little and you will bob on the surface like a cork. Risk adjustment in value-based care has some similarities: a successful VBC program will diagnose and treat just the right conditions. Not over-coding, and not under-diagnosing. 

 

Clinicians learn HCC coding better in clinical vignettes

And doctors coming out of medical school and even residency programs know little to nothing about HCC coding and diagnosing for Risk Adjustment and Value-Based Care. Traditionally, these clinicians sit in seminars getting force-fed codes in an effort to teach them how to accurately diagnose and document with the appropriate HCC codes. Unfortunately, this is not how every other vital piece of medical information was learned, so clinicians struggle to retain the information and utilize it in daily practice. 

 

Medical education is all about the Socratic method, question and answer, clinical vignettes. Doctors learned to learn this way, and they prefer it. Which is why DoctusTech helps doctors learn HCC coding the way they like to learn – from other doctors, in clinical vignettes, on their own time, and in an average of 5 minutes per week.

 

Truly, DoctusTech helps clinicians learn HCC coding. And when clinicians master diagnosing for risk with HCC codes, your whole VBC program improves. 

 

See more ways that DoctusTech Helps:

  • DoctusTech Helps: Increase RAF Accuracy
  • DoctusTech Helps: Decrease clinician workload
  • DoctusTech Helps: Deploy HCC coding education across your org 
  • DoctusTech Helps: Change Clinician Behavior
  • DoctusTech Helps: Value-Based Care
Everything You Need To Know About HCC Coding TrainingPosted on

Everything You Need To Know About HCC Coding Training

Everything You Need To Know About HCC Coding Training

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

 

What is HCC coding?

Hierarchical condition category (HCC) coding was created to estimate future health care costs for patients. The Centers for Medicare & Medicaid Services (CMS) HCC model was established in 2004 and is increasingly being used as value-based care gains traction. The HCC model relies on ICD-10-CM coding to assign patients risk scores based on their medical condition. Each condition is associated with an ICD-10-CM code. For example, a patient with few serious health problems is likely to have average health care costs for a specific period of time. Patients with many chronic conditions, however, are more likely to have higher health care utilization and costs.

 

Why is HCC coding training so important?

As we mentioned above, proper healthcare coding is important for a number of reasons. However, even the best healthcare providers cannot properly code without the right training. If you are new to the healthcare industry, you will need training to learn the coding system and understand the complexities of accurate diagnosis and documentation. If you have been in the industry for a few years but have not kept up with the latest coding trends, you may also need training to refresh your skills. Whatever your situation, it is important to take the time to invest in HCC coding training. This training will help you master the terminology and coding systems that are used in the healthcare industry. It will also help you learn how to properly diagnose and document for better patient care.

 

Which platforms and tools are effective?

HCC coding training can be delivered in a variety of ways. Depending on which courses you decide to take, you may be able to access them online or on your mobile device. Most HCC coding training courses will include videos, interactive activities, and practice tests. These tools can make learning easier and more effective. They can also help you retain the information you learn effectively. If you are looking for HCC coding training, it is important to find a platform or a course that fits your learning style and skill level. If you are new to the industry, you may want to take a beginner’s course. If you have been in the industry for a few years and just want to refresh your skills, you might want to take an intermediate or advanced course.

 

3 Things to include in your training plan

When you are ready to start your HCC coding training, it is important to make sure you have a plan in place. This will help you stay motivated and on track and make sure you finish before the course’s deadline. There are a few things you should definitely include in your plan.

 

Set specific goals

Before you begin coding training, you should sit down and set some specific goals for your course. What do you hope to achieve by the end of your training? By setting specific goals, you will know what you are working towards and have something to motivate you. 

Set a schedule

It is important to set a schedule and stick to it. This will help you stay motivated and make sure you do not get overwhelmed by the coursework. Make sure you allot enough time for studying each week and do not try to cram. A healthy pace is achievable at 5 minutes per week, if you have the right tools. 

Stay focused

Finally, during your coding training, it is important to keep your eye on the prize. While coding is interesting and can be complex, you do not want to get so involved that you lose sight of your goal. Stick to your schedule, do not try to push yourself too hard and you will be on track to finish in time.

 

Get Started Today

Doctus Tech is the best way for clinicians like yourself to start learning to diagnose with HCC codes. Benchmark yourself with other clinicians, identify your team’s knowledge gaps and benefit from a 30% increase in RAF accuracy. Sign up for a 14-day trial now!

Risk Adjustment CodingPosted on

Risk Adjustment Coding – Challenges And How To Get It Right

Risk Adjustment Coding

Risk adjustment coding is a vital part of any managed care organization. It helps to ensure that patients are appropriately diagnosed and documented accurately according to risk level, which in turn allows the organization to receive appropriate capitated payments to provide all the care needed to reduce avoidable hospitalizations and achieve maximum health. And regardless of how  challenging and time-consuming it can be to implement, getting it right is vital on many levels. Diagnosing and coding for risk can be tricky. 

 

It is not always obvious how complex and risky a condition is, especially because some patients are at higher risk than others for diseases like depression or schizophrenia, but many conditions can be difficult to diagnose. Those who appear low-risk might actually be high-risk, once you dig deeper into the specific diagnosis details. There are thousands of potential codes and conditions to diagnose that can be used to determine risks. There is no perfect formula for every managed care organization; you have to find protocols for training and improvement that work best for your clinicians and operators. Let’s take a look at some of the challenges involved in risk adjustment coding and how to get it right.

 

Determining risk is difficult

When implementing a risk adjustment program, make sure you have a team on hand with strong coding and data management skills. These team members should be able to look at each patient record and determine both the conditions that have been diagnosed as well as the documentation criteria to be  applied to that patient in the chart. This team will be responsible for determining and documenting  diagnoses that correlate to the risk level of each patient. This task can be difficult since mastering HCC coding for risk adjustment requires a lot of learning and is often different than standard ICD-10 coding. But there are modern tools for mastering this, so do not lose hope.

 

Risk adjustment requires a lot of data

Risk adjustment also requires a lot of data. The more information you have about each patient, the better you are able to diagnose based on their true conditions and related risk. If you do not  have enough data about a patient, or lack consistent data throughout the lifetime of a patient relationship, you will have a hard time determining their true risk level. 

 

For example: Patient A has been a patient for 10 years, and Patient B has been a patient for 2 years. If you’re trying to diagnose the patients, you’ll have to take into account their lifelong risk factors and current health status. This includes things like socioeconomic status, age, family history of certain diseases, how much they smoke, and more. If you have a few years of data points on Patient A, and only a few months of data points on Patient B, you’ll be able to diagnose Patient A more accurately.

 

Coding errors are common

Coding errors are common in risk adjustment, but they can be avoided with consistent training, accountability, strict internal audit procedures, and improved clinician buy-in. Coding errors can lead to overcharging or undercharging the CMS, resulting in either missed earnings or painful charge-backs. Coding errors can be caused by a number of different factors. For example, mistakes could be made when determining which diagnoses apply to patients, which codes to use for the diagnoses, or what to document to justify the diagnosis in the chart. Diagnoses require clear communication as well as consistent documentation on all patient records.

 

It is only going to get harder.

The bad news is that risk adjustment is only going to get harder. New technologies like AI, voice recognition, and machine learning are changing the way health care providers analyze and manage data. While these technologies will make many aspects of coding and managing data easier, they will also make it more complex by introducing even more variables and data points to consider. So while risk adjustment could be more challenging, there are tools available that simplify the process both in training and inside the EMR.

[Book a Demo]

Conclusion

Risk adjustment is vital, because it ultimately determines what type of care an individual patient needs and how much risk the organization is taking on, managing that care. It is important to ensure that your organization is accurately diagnosing and documenting so that patients stay healthy and your organization has the needed revenue to manage their care.

OIG 13 percent of Medicare Advantage Prior Authorizations Inappropriately DeniedPosted on

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].

HCC Coding and Physician BurnoutPosted on

HCC Coding and Physician Burnout

HCC Coding and Physician Burnout

RaDonda Vaught was just sentenced to three years of supervised probation. The former Vanderbilt University Medical Center nurse was found guilty of negligent homicide and gross neglect of an impaired adult in the death of a patient, because she administered vecuronium rather than Versed.

 

A tired, overworked nurse could not find the prescribed medication in an automatic drug dispensing cabinet, so she used an override and grabbed the wrong drug. Her patient died, and she was convicted of two felonies.

 

Burnout is a pervasive evil in any industry. But in healthcare, the stakes are measured in lives, and a career-ending error could also land a well-meaning provider in court, battling more than a malpractice suit. 

 

The Rise and Fall and Rise of Physician Burnout

A study from 2019 demonstrated a decline in physician burnout [Source]. Good timing, as the burnout decline preceded an overall healthcare worker burnout event rivaling the black plague at a drag strip. Just one year after publication, COVID-19 ushered in the worst, longest, darkest season of overwork, stress and burnout the healthcare industry has seen in a century. 

 

And with the industry marching predictably toward Value-Based Care, onboarding a new clinician comes with a massive learning curve. Requiring providers to add HCC coding to their already complex workflow is not only vital to improve the industry, it is increasingly mandated by CMS.

 

Add to it that none of this HCC coding was taught in medical school, and you have a perfect storm that even Clooney & Wahlberg would struggle to make sexy. 

 

Why do they make it so hard?

The rising tide of burnout and the steady growth of VBC and HCC coding knowledge form enough of a riptide of impossibility for today’s practitioners. But the teaching methods being used to bludgeon new codes into the weary minds—and workflows—of new residents and established docs alike are downright cruel. Consider that HCC coding education is  being deployed using some of the most arcane and ineffective teaching tools available today. 

 

1 hour seminars are the lingua franca across nearly every provider group in a risk payment model. And if sitting in a classroom being talked at while pretending not to stare blankly at your phone was not bad enough, the two worst years in most providers’ careers were met by shifting those interminable seminars to a Zoom call, probably on your phone.

 

Consider the vital role that HCC coding plays in capturing critical diagnoses to be treated, documenting those diagnoses to keep them treated, and billing against Risk Adjustment scores to reimburse for essential healthcare services that keep patients out of the hospital. 

 

And we are teaching these skills over a Zoom call? With providers more burnt-out than ever, and Zoom fatigue at a universal high – we are lecturing doctors on HCC coding over their phones? Is it a surprise that engagement is low? Is it a surprise that errors are high? Or that adoption of full risk models is sluggish at best? 

 

And yes, one-to-one coaching is the gold standard, and those who provide this mission-critical service should be heralded in the streets and welcomed with ticker-tape parades. This is heroic work. But with global workforce shortages, there are definitely not enough coaches to tackle the task at hand. Not for all the clinicians in desperate need of a rapid increase in their fund of knowledge on VBC and HCC coding. 

 

Is there really no other way? 

 

Full disclosure: this is a blog post by a brand that has pioneered another way to teaching HCC coding to doctors. And it really works. But we are not here to sell you our solution. At the moment, we are only here to say as loudly and as clearly as we can that Ye Olde Ways™ are not working. And if there is a better way—which there is—we need to be running toward it like actual lives depended on it. And not just patient lives – doctor lives, nurse lives, NPs and PAs and coders and operators and the IT team, too. There is a lot at stake, and it’s time to search for answers. 

 

Our Offer

If HCC Coding and Physician Burnout are at all on your radar, we’d love to share a solution to both. Better solutions are out there – and they outperform seminars and code-of-the-month email blasts for engagement and results. And they free up your coaches to focus on the 20% that need it the most. 

To learn more, book a conversation with our team!

 

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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!

Full Risk Value-Based CarePosted on

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 - HCPLAN APM alternative payment model Framework- Value-Based Care Payments IncreasingPosted on

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!

 

HCC Coding Education For Family Physicians.pngPosted on

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.

Posted on

HCC coding education for doctors: The easy way

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 can’t diagnose what you don’t document.

 

And you can’t 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?

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.

  2. Schedule a demo to learn more about the app today

1. Why is HCC coding education essential for clinicians?

Because accurate HCC coding drives RAF accuracy, and RAF accuracy drives revenue in Value-Based Care. Without proper documentation, organizations under-code, under-report disease burden, and lose the resources needed to care for patients.

2. Why doesn’t traditional HCC training work?

Lectures, Zoom sessions, and code-of-the-month emails create short-term awareness but no lasting behavior change. Clinicians quickly revert to old habits because the training feels disconnected from real clinical work.

3. What’s the most effective way for doctors to learn HCC coding?

Through active learning, clinical vignettes, quick scenarios, and immediate feedback. This mirrors how doctors learned medicine and builds real, lasting behavior change.

4. How fast can clinicians improve with the DoctusTech HCC Coding App?

In just a few minutes per week. The app fits into a clinician’s day, teaches through real-world cases, and delivers immediate documentation improvements, often within the first 30–60 days.

5. Does the DoctusTech HCC Coding App offer CME?

Yes! Clinicians earn 25 hours of CME per year simply by completing HCC lessons. That turns required learning into a rewarding, high-value experience that providers actually enjoy.

HHS secretary Xavier Bacerra on overcoding in medicare advantagePosted on

HHS Secretary Becerra Addresses Upcoding in Medicare Advantage

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 DCE CMSPosted on

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 Equity, the new model looks to improve upon DCE without replacing it entirely.

 

Download the full CMS webinar presentation deck, and read our interpretation of the new guidelines.

Access the full report below.

 

 

Posted on

VBC Strategies for 2022: What to STOP, START and CONTINUE?

 

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 Risk adjustment coding in medicare shared savings program HCC MSSPPosted on

How the MSSP Rule Reshapes Risk Adjustment Coding for ACOs

ACOs Risk adjustment coding in medicare shared savings program HCC MSSP

Quick glossary

CMS = Centers for Medicare & Medicaid Services
MSSP = Medicare Shared Savings Program
ACO = Accountable Care Organization
HCC = Hierarchical Condition Categories
RAF = Risk Adjustment Factor

 

CMS released its final Medicare Shared Savings Program rule, called Pathways to Success, for ACOs. The new rule is designed to help establish a path toward risk, with a heavy focus on risk adjustment coding.

 

MSSP outlines a clear transition to risk, allowing ACOs to start at different points, depending on their current organizational status. It extends the agreement period from 3 to 5 years, which provides more time to measure performance against the benchmark. This creates Basic and Enhanced track options en route to risk (see Image A).

Why Risk Adjustment Coding in MSSPs and ACOs matters now

 

Many ACOs historically deprioritized HCC coding because benchmarks leaned heavily on past performance and offered little reward for better specificity. Pathways to Success removes key limitations and introduces a 3 percent cap on upward RAF changes from historical to performance year, altering the incentive math. If your RAF dipped between BY3 and PY1, you can improve beyond 3 percent to offset prior declines.

 

Image A Basic & Enhanced Tracks

Basic & Enhanced Tracks Risk Adjustment Coding
Risk Adjustment Coding Basic & Enhanced Tracks

Why ACOs that skipped HCC coding should reconsider

 

The adoption of HCC risk adjustment best practices has been recognized by Medicare Advantage plans for several years. In contrast, ACOs that participate in the Medicare Shared Savings Program (MSSP) have opted out of any type of program, as they felt it had little effect on their benchmark. This is often due to an ACO’s 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 to the true risk score; therefore, no penalty was applied for similar low risk scores year over year.
    • False or inaccurate predictions of condition profiles of beneficiaries.
    • Re-enrolled beneficiaries were given a demographic adjustment only, making it very difficult for an ACO to improve coding and increase benchmarks.

 

What changed: 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 percent limit on the total increase from the historical year to the performance year.

 

The data signal ACOs cannot ignore

 

ACOs continue to lag in the adoption of HCC coding practices. According to the most recent 2019 Shared Savings PUF file, 49% of groups have experienced a decrease in RAF from the benchmark year 3 (BY3) to the 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.

 

Key implication: Coding improvements are capped at 3 percent; however, the prior drop from BY3 to PY1 means an ACO can improve above the allowed 3 percent in net effect because the increase is measured against the historical performance year change. In practice, that means there is room to regain lost ground.

 

Image B: RAF Decrease PUF file 2019 ACO MSSP

Risk Adjustment Coding

What “good” looks like: best practices you can adopt now

 

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 provide a more accurate way of predicting cost and determining reimbursement.

 

By adopting best practices in HCC coding, you can ensure that your medical group achieves the highest specificity in diagnoses, thereby ensuring quality of care and compliance.

 

What exactly are these best Risk Adjustment Coding practices that can be adopted?

 

1) Educating Providers

    • Short, recurring training focused on common chronic conditions, MEAT criteria, and documentation specificity.
    • Practical pocket guides and quick tips embedded in the workflow.

 

2) Making correct preparations before an encounter

    • Pre-visit summaries that surface suspected but unconfirmed conditions, open care gaps, recent hospital or ED use, and last-year HCCs that require recapture.

 

3) Documentation of all current chronic conditions

    • Assess, treat, and document active conditions that affect care, even if not the chief complaint.
    • Include status, control, and current plan. Avoid vague terms.

 

4) Ensuring a clean clinical workflow to display conditions for clinicians

    • One screen or panel that cues accurate HCCs

 

5) Post-encounter review for quality assurance

    • Same-day or next-day audits of a small sample to catch unsupported codes, missing MEAT, and upcode risks.
    • Rapid feedback loop to the clinician.

 

Building the engine: data you will need and how to make it actionable


As value-based care is being adopted on a broader scale, the traditional fee-for-service payment model is slowly being replaced. More time is being spent with patients to treat all chronic conditions during the encounter, which is becoming a best practice.

 

One of the major issues that medical groups contend with is the ability to utilize all relevant data to create an aligned clinical workflow that helps physicians recapture, diagnose, and reject any inaccurate conditions. 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 learn how we address Risk Adjustment Coding 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 Risk Adjustment Coding easy

 

What is Risk Adjustment Coding in MSSP and ACOs?

Risk adjustment coding in the Medicare Shared Savings Program (MSSP) allows Accountable Care Organizations (ACOs) to document patient complexity more accurately. By capturing Hierarchical Condition Categories (HCCs), ACOs can more accurately predict costs, establish fair benchmarks, and enhance reimbursement while maintaining compliance.

What are the best practices for ACOs to improve risk adjustment coding?

Leading ACOs focus on provider education, pre-visit preparation, documentation of all chronic conditions, integrated workflows for clinicians, and post-encounter quality review. These steps ensure specificity, compliance, and higher RAF recapture rates that align with MSSP goals.

How can technology support ACOs in risk adjustment coding?

Technology solutions—like DoctusTech’s tools—integrate claims, pharmacy, eligibility, and historical diagnosis data into actionable insights. They streamline workflows, flag documentation gaps, and ensure MEAT compliance, allowing clinicians to focus on patient care while ACOs improve RAF scores and financial outcomes.

HCC Coding ProgramPosted on

5 Strategies for a Highly Effective HCC Coding Program

HCC Coding Program

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 failure to act can lead to lost revenue and significant audit penalties. And inaction on your part will result in immediate loss of revenue and exposure to heavy audit penalties.

 

Whether you’re building a program from scratch or already have a program in place, the top five strategies for a successful program include:

 

    • Clinician Education — One-hour seminars or “codes of the month” emails don’t work.

 

    • Concurrent Chart Audits — This is more than checking boxes in the EMR to drag and drop chronic conditions into the progress note.

 

    • Point-of-care Clinical Guidance — Clinicians work under time constraints and manage complex cases, making it challenging to recall every diagnosis and guideline. Reliable clinical support helps ensure accurate documentation without adding to their workload.

 

    • Data Analytics — While data analytics can seem overwhelming, it doesn’t have to be. Concentrating on a few key areas can drive a more effective program.

 

    • Accountability —Achieving coding accuracy is a team effort. No single person should be held liable to be commended for the results.

 

HCC Coding Program
HCC Coding Program Photo by RODNAE Productions from Pexels

 

Let’s dive deeper into your HCC Coding Program.

CLINICAL EDUCATION FOR YOUR HCC CODING PROGRAM

Clinicians, on average, retain 15% of any educational seminar they attend after residency. Even with 15% knowledge retention, there is a consistent regression to the mean after eight weeks. Out of sight, out mind!

No one size fits all, but we know the Socratic method of teaching, consistent education, and regular feedback result in sustained behavior change among clinicians.

 

Socratic method

Stop teaching at doctors and start objectively testing their knowledge. Try clinical vignettes in small group settings. Problem-based learning is how most medical education is practiced today, yet coding education has not caught up. Customize training to your clinician skill sets and practice patterns to improve buy-in.

 

Consistent education

Training is done once a quarter or via email will consistently fall flat. Clinicians have a lot going on, and to cement, any new information must be presented to them multiple times and in various ways. This doesn’t have to be time-consuming but it does need to remain consistent.

 

Regular feedback

Clinicians always strive to be better. So, customized feedback on documentation accuracy and opportunities for improvement are critical. Rather than focusing only on clinic-based or team-based results, ensure each clinician understands their individual strengths and weaknesses compared to the group.

 

Clinicians, on average, retain 15% of any educational seminar they attend residency.

CONCURRENT CHART AUDITS

This will help in two ways: a) ensuring compliant documentation and b) adjudicating claims before submission.

A typical clinical documentation improvement program ensures that over- and under-coding are corrected before billing. Typically, institutions “hold” a bill for two business days to make any corrections. During this period, the provider can be asked to clarify inaccurate documentation and adjudicate the superbill to ensure proper 1:1 matching with progress notes to billable codes. Much of this is currently handled at the payor level for smaller physician groups.

 

As you start to take on more risk with your practice, you’ll need a consistent strategy across all your payor contracts. While vendors are currently using a heavily manual process, emerging technology from DoctusTech will help you do this at the point of care with our A.I. This will drop your OpEx, decrease your risk during RAD-V audits, and give you a more accurate line of sight to your risk scores.

POINT OF CARE CLINICAL SUPPORT IN YOUR HCC CODING PROGRAM

 

Doctors were not trained as coders, and coders were not trained as doctors. The basic premise of accurate documentation is and should be clinical. Clinicians need to take better histories, perform more accurate physical exams, and synthesize data to make clinical diagnoses. No coder or AI can replace and find these diagnoses, as the data is inherently flawed and has significant gaps.

 

DoctusTech helps clinicians ask more insightful questions, conduct thorough exams, and access clinical guidelines to let them take care of their patients. This will inherently improve your RAF accuracy and create physician buy-in better than any other product. 

 

Unfortunately, EMRs are limited by their data sets. They operate only off the information inputted, so if your PCP doesn’t have the complete clinical picture from your hospital systems and your specialists inputted into the EMR, the clinical decision support in your EMR will be lacking.

 

 

HCC Coding Program
HCC Coding Program Photo by energepic.com from Pexels

 

DATA ANALYTICS

No pilot would fly a plane without an operational dashboard, so why do we allow the same for such a critical part of our value-based care business? No excuses, no delays. The ability to aggregate data from outside your EMR, deliver individual physician report cards on HCC documentation, and have visibility to patient annual wellness visits (AWVs) for everyone on the team is critical. If your team doesn’t have the bandwidth, outsource it. Time is critical, and the ROI is clear.

 

Remember, if the data is not easy to fetch and easy to understand, no one will use it. This does not need to be an expensive endeavor. Make sure you have visibility to the following data points by an individual physician.

ACCOUNTABILITY

Whether you plan to use a stick or a carrot approach to accurate documentation, the strategy needs to be intentional and meaningful. The entire team plays a role in an effective program, and accordingly, the strategies you deploy should touch each individual team member in a meaningful way. Rewards do not need to be financial, and the motivation here is it drives better clinical care. The emphasis in the following areas are compliant and effective:

    • Documentation accuracy
    • % AWVs scheduled
    • Regular engagement with any coding tools

 

DoctusTech’s proprietary AI can be embedded into your EMR or on your phone to help you effectively complete steps 1, 2, 3, and 4. All you have to do is be ready to hold your team accountable.

 

Want to see how DoctusTech can streamline your HCC Coding Program? Schedule a demo today!

 

 

What are the key strategies for building an effective HCC coding program?

The key strategies for an effective HCC coding program include clinician education, concurrent chart audits, point-of-care clinical guidance, data analytics, and accountability. Each plan is crucial in improving documentation accuracy, ensuring compliance, and optimizing risk adjustment factor (RAF) scores in value-based care settings.

How can clinician education improve HCC coding accuracy?

Clinician education improves HCC coding accuracy using the Socratic method, consistent training, and regular feedback. Personalized training sessions and ongoing education help clinicians retain crucial coding knowledge, leading to better documentation and reduced errors. Regular feedback ensures continuous improvement in coding accuracy.

Why are concurrent chart audits essential for HCC documentation compliance?

Concurrent chart audits are essential because they ensure that documentation matches billable codes and complies with coding guidelines before submission. By conducting audits during documentation, physician groups can identify and correct errors in real time, reducing the risk of audit penalties and improving reimbursement accuracy.

How can point-of-care clinical guidance enhance RAF accuracy in value-based care?

Point-of-care clinical guidance enhances RAF accuracy by giving clinicians real-time access to relevant clinical data and guidelines. This guidance helps clinicians make more accurate diagnoses and document conditions correctly, ensuring that all relevant chronic conditions are captured and improving the overall risk adjustment score.

What data analytics metrics should physician groups track for successful HCC coding?

Physician groups should track several key data analytics metrics to ensure successful HCC coding, including patient panel data, suspect vs. chronic diagnoses, the completion of annual wellness visits (AWVs), and documentation accuracy. Tracking these metrics enables better insight into coding performance and helps identify areas for improvement in documentation practices.

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What is HCC Coding: Risk Adjustment Models in Value-Based Care

As healthcare continues shifting from fee-for-service (FFS) to value-based care (VBC), accurate documentation and coding have become more critical than ever. Hierarchical Condition Category (HCC) coding is at the heart of this transition.

 

In this article, we’ll explore the fundamentals of HCC coding, how it impacts reimbursement, and why providers—even those outside of VBC—should take notice.

 

What is HCC coding? 


HCC stands for hierarchical condition category. It is a risk-adjustment coding model exclusively designed to estimate future healthcare costs for patients. The process of HCCs medical coding started in 2004, but it recently gained popularity due to payment models shifting from fee-for-service (FFS) to value-based care (VBC) arrangements.

 


Fig 1. Out of 70,000+ ICD10 codes, 7903 ICD-10s map to a hierarchical condition category. Each HCC ICD10 is subsequently bucketed into 115 individual “condition categories.

 


Fig 2. Each of the 7903 HCC codes is put into one of 115 condition categories. Each condition category carries a specific RAF. No matter how many ICD10 conditions a patient has in the same category, they will only be assigned the RAF score one time

 

Medicare assigns a risk score known as a risk adjustment factor (RAF) to each of the 86 individual condition categories. RAF scores of patient populations are subsequently used by Medicare and other payors to predict the cost of care, which influences reimbursements.

For the remainder of this article, we will explore the rationale behind HCC coding and why all providers (even those NOT in a value-based care arrangement) should care.

Why should doctors care about HCC coding?

HCC coding is the cornerstone of most value-based care arrangements. Today, “value-based care” is used synonymously with Medicare Advantage, but in the near future, we believe all forms of reimbursement will be tied to some VBC arrangement.

 

HCC coding falls under the broader term of risk adjustment (RA) models, where patient care is paid based on a prospective payment model. Specially designed RA models are used to determine risk scores for patients. In the Medicare Advantage world, these models use the demographics and HCC diagnoses of the patient to assign a risk score known as an RAF. The assumption is that the sicker the patient, the higher the RAF, and the more dollars it will take to care for this patient during any given year. Therefore, the RAF score of any patient population will determine the prospective payment Medicare disburses.

This prospective payment model based on RAF does 2 things:

 

1. Aligns physician incentives. Currently, clinicians make money from taking care of sick patients. The sicker the patient, the more visits, tests, or surgeries they have to do, and the more they are reimbursed. In this model, clinicians are incentivized to keep patients healthy and, therefore, require fewer tests and surgeries.

 

2. Spurs clinical innovation the right way. Right now, pharmaceuticals and medical hardware companies are all trying to find ways to treat diseases. The newer the drug or medical device, the more revenue they make. In this model, healthcare groups are incentivized to find new ways of preventing the disease progression from ever needing the latest drug or newest medical surgery equipment.

 

As Medicare and payers alike are starting to take notice of #1 and #2 above, the market is now trending towards building in value-based care drivers to all types of patients outside of Medicare Advantage. It’s unlikely a brand new risk model will be born for commercial patients. Therefore, all physicians will need to understand the risk adjustment models and the implications of documentation accuracy for reimbursement.

Conclusion

 

HCC coding is here to stay and will only grow in the years to come. While the market has heavily leveraged medical coders or third party vendors to do much of the lift thus far, V2 of Value-based Care will require all clinicians to understand and participate in it for every patient visit.

 

HCC coding’s importance is less about the impact on revenue and more about the shift toward VBC models, which have consistently shown better clinical outcomes at lower costs. 

 

Do you want to dive deeper into the financial implications of HCC coding and HCC coding tools? Read more in our VBC hub! 

 

Sources
https://www.asahq.org/quality-and-practice-management/managing-your-practice/timely-topics-in-payment-and-practice-management/an-introduction-to-hierarchical-condition-categories-hcc
https://www.aafp.org/fpm/2016/0900/p24.html

 

What is HCC coding in healthcare?

HCC (Hierarchical Condition Category) coding is a risk adjustment model used in healthcare to predict future medical costs for patients. It categorizes diagnoses based on severity and complexity, allowing payers to adjust reimbursements accordingly. HCC coding ensures that providers are properly compensated for treating high-risk patients.

How does HCC coding impact Medicare reimbursements?

Medicare uses HCC coding to determine reimbursement rates by assigning each patient a Risk Adjustment Factor (RAF) score based on their diagnoses. The higher the RAF score (indicating a sicker patient), the more Medicare will pay providers in a value-based care (VBC) model. Accurate HCC coding is crucial for ensuring fair and sufficient funding for patient care.

What is a risk adjustment factor (RAF) score in HCC coding?

A Risk Adjustment Factor (RAF) score is a numerical value assigned to patients based on their diagnoses, age, and demographics. Medicare and other payers use this score to estimate the cost of care for each patient. The higher the RAF score, the more financial resources are allocated for that patient’s healthcare needs.

How are ICD-10 codes mapped to HCC categories?

ICD-10 codes are mapped to HCC categories based on the severity and complexity of the diagnosed condition. Out of over 70,000 ICD-10 codes, approximately 9,500 are associated with one of the 86 HCC categories. Each ICD-10 code corresponds to a specific condition category in the HCC model, which reflects the patient’s risk of future healthcare costs.

Why should doctors outside of value-based care pay attention to HCC coding?

HCC coding isn’t just about reimbursement—it directly affects patient care. Accurate risk adjustment ensures that providers have a complete picture of a patient’s health, leading to better care coordination, appropriate treatment plans, and improved outcomes. As more healthcare models adopt risk-based payment structures, properly documenting chronic conditions will help ensure that patients receive the right care and support, regardless of the payment model.