Watch the full interview here!

Levi Wiggins: On another episode of Live with Dr. Kazi! You are a population health expert & co-founder of DoctusTech. And today we’re going to do a bit of a deep dive into the recent case of the Department of Justice and whistleblower Cathy Ormsby against Sutter Health and Affiliates, with their false claims act violations, alleged, and the $90 Million settlement.

What is the first thing you think when you hear about that case? 

 Farshid Kazi MD: It makes me sad. I mean, I think a lot of us providers know that there’s a lot of pressure around documentation accuracy, and it felt like it was a Swiss-cheese effect. I have to think that my colleagues in the field of value-based care are trying to do everything right.

Always trying to be accurate and document appropriately. But sometimes, when you set up systems in piecemeal, there’s not a proper safety net to catch when multiple errors happen, the perfect way. And unfortunately, that was what the situation looks like it could have been at Sutter Health. 

Levi Wiggins: I mean, in the, the big 45 page piece that the DOJ released, there were a lot of different parts that got highlighted. And I think we were discussing earlier some of the things that they did make perfect sense, like that’s a good idea, right? 

Farshid Kazi MD: Yeah. That’s right. You want to bring in your patients once a year, talk about the medical conditions, talk about what’s happening, make sure that everything’s safe at home.

Really try to plan ahead for the following year. So the concept around an annual wellness visit. Completely kosher. It’s actually encouraged and something that us providers look forward to doing. And oftentimes during those visits, you will document HCC diagnoses. These are things that the patients have.

You want to talk about it with the patients. Tell the plans, tell the Medicare, talk about what their medical conditions are, and also think about what you’re going to do preventatively for that following year. And during that visit, you’ll often document HCC diagnoses, and sometimes programs will provide providers with all the information possible so they can properly document during that visit.

But what you want to do is be careful that you’re not helping increase the up documentation or up-coding and making sure on the backend, everything is compliant. And sometimes if you’re just focusing on the documentation, and making sure the diagnoses are in the chart before claims is submitted and not thinking about the compliance piece, that’s kind of where you can end up in Sutter’s situation.

Levi Wiggins: Now, I read that they set a goal to increase their risk adjustment scores by 28%.  It seems a little high. 

Farshid Kazi MD: Yeah, nationally, the average is around 3%. When you think about risk adjustment going up every year. And so typically, we never try to tell providers, “we have a target on which we want to increase the RAF.”

It’s more about how do we improve our accuracy. So thinking about both up and down. So if you’re having diagnoses that you’re carrying over that are inaccurate, really trying to empower your providers to say, “Hey, this should not be submitted.” Or “this is inaccurate,” is the right way to think about it.

So, setting a goal of 28%, again, not having been in their shoes. Perhaps it was more around increasing their accuracy and not necessarily increasing the score, which would be a no-no. 

Levi Wiggins: And how do you feel about a coder coming in after the encounter and adding a few codes that the clinician may have just simply overlooked.

Farshid Kazi MD: You know, what Sutter had in place is no different than multiple groups across the United States. They have work being done before the patient visit, they have worked being done after the patient visit; coders are an integral part of the team to accurately reflect the work that providers are doing with patients.

And the problem comes when you’re suggesting diagnoses to providers who have not necessarily been educated around why that’s being presented in front of them and given them a workflow that allows them to only check boxes to carry diagnosis over so they can get through the workday. 

The key really here is, are you giving the right information, educating the providers and allowing them to make a clinical decision? So when you have a coder coming in and suggesting something that wasn’t necessarily documented at the point of care, it becomes a little bit more of a gray area. And you want to be very clear that your provider understands why they’re being suggested that diagnosis.

And then given the power to say yes or no one, either direction. 

Levi Wiggins: We talk about a lot of risk adjustment, but the risk to providers that this case seems to indicate is that not just CMS, but also the DOJ is very concerned – this is the first time I’ve seen the, the word mischarging. Talk about the risk to provider groups, now. 

Farshid Kazi MD: Yeah. I mean, this is a whistleblower case, right? So we know that the reason that the DOJ looked at this was because someone raised their arms and said, “Hey, this doesn’t feel right.” RADV audits are another way to prevent abuse of the Medicare advantage documentation compliance programs.

But that right now is focused just on payors. Every time we talk to provider groups, or I speak with a colleague, I’m always trying to encourage them to think about compliance more than RAF accuracy, because it’s only a matter of time with the Direct Medicare Contracting model. ACOs taking downside risk that provider groups who are taking on this risk are going to be held accountable in the same way that a payor is.

And so it’s unfair for us to say, look, we submitted a clinical diagnosis without justification. It’s up the plan to figure out whether we are compliant or not. And then we’re shielded by the plan. So right now, all audits through MA plans are happening at the payor level. But I’m really confident it’s only a matter of time before it starts coming back to us provider groups.

So this, if nothing else, should make people a little nervous, or do they have the right processes in place? Are you educating your providers to understand the “why” around risk adjustment? Am I accurately documenting? Do I have the right justification? And am I given the right amount of time to say yes or no to these diagnoses?

If you don’t have the right information, you should not be carrying over any diagnosis. That is just a yes, because it’s going to make your boss happy or make you get through the day easier. So making sure that conversation is happening is integral to making sure that the next piece- which is compliance- is happening.

Levi Wiggins: So as we kind of peer over the garden wall here into Sutter Health’s dealings, obviously, no admission of wrongdoing was made in a $90 million settlement, but from out here, what do you see that they could have, or should have done differently or better? 

Farshid Kazi MD: I think if you think about risk adjustment strategies, when you think about it in a pyramid, the foundation on which you build risk adjustment should really be around empowering, educating, and giving knowledge transfer to providers so that they can make clinical decisions.

So what is it that they’re doing? Why are they doing it? And then what should they do if they see a mistake? And so if that foundation was built, I suspect that the providers would be able to stand up and say, “Hey, some of these diagnosis that you’re putting it in front of me are inaccurate!” And a big mistake that was seen not only at Sutter, that I see across the United States, is acute diagnoses are being carried over year over year.

Meaning things like acute stroke, acute heart attack. That should not be coded in a patient the next year – or a malignancy that’s been resolved. And again, being carried over because someone gave a fax paper or a piece of paper to a doctor and said, can you please check yes or no to these diagnoses?

And maybe the provider thought, “Hey, the patient did have this at some point” But didn’t realize that this is not something that happened this year. And that’s up to, again, building the knowledge around what you’re trying to do. Putting the infrastructure in place so that you’re catching and saying, “Look, an acute diagnosis carried over year over year. Let’s go back to this provider. Did this patient really have two strokes? Two consecutive years?”

Maybe it’s yes. Maybe it’s no, but there needs to be a process around catching that. So I think building knowledge, having point of care workflow to empower your docs and then really building a solid foundation around compliance is going to be key.

Levi Wiggins: That’s good. I like that. One thing that we saw in this specific case is they were accused of intentionally coding unsupported diagnoses, and then finding them and not paying back – on purpose. So when we talk about increasing accuracy, talk to me a little bit about the process. I guess how you run a business, looking at money you’ve you’ve gotten and how to give that back in a way that’s ethical and reasonable.

Farshid Kazi MD: Yeah. I mean, it’s really hard to give money back once you’ve gotten it. So the best approach is really, don’t take the money if you’re not deserving of it. So really making sure that before the diagnoses go to claims, and then go to the payors, and then Medicare, you know, with full confidence, that they actually existed in the patient chart.

So one thing I always coach and work with provider groups is saying, what are the diagnoses that are acute? You don’t want to carry over and make sure that’s a no-no. But the second piece is let’s talk a little bit about, at the point of care. As the doctor’s writing the note, is there a way to catch and make sure that there’s compliance there before you even submit the bill?

And if not, let’s make sure we’re doing some audits and charts to give some confidence to you as an organization that you’re not receiving any reimbursements for diagnoses that are inaccurate. 

And then the second piece to that is once you’ve done, that is having a retrospective aspect of let’s do some charts on. Let’s look through this and make sure we’re paying back appropriately because compounded over time. That can be a massive bill as well. 

Levi Wiggins: Okay. So as we, as we look into the future here I mean, the whistleblower case is, is one avenue. The RADV audits are another avenue. But I guess what, what is, what is the risk level for, for a doctor? Like, what’s the likelihood of getting caught at this point. 

Farshid Kazi MD: Yeah. You know, is something morally wrong only if you get caught, right? We could talk about that forever. But to me, it’s a question of do the right thing. The first time around. I think all providers have gone into the field because of that same level of commitment to their patients.

So if you are in value based care, because you care about delivering better care. And you think you can do it at a lower cost. Risk adjustment is a necessary part of that, but do it right the first time. So document accurately. And I think that the two pieces that provider groups should be worried about is there’s a significant risk to them.

That Medicare is going to now start to audit provider groups as the risk is passed from payors to provider groups. And the two things that I see all the time that providers are doing incorrectly is one, they’re carrying over acute diagnoses. And two, when they’re putting the diagnoses in there, they’re not necessarily justifying it.

They’re being told by their group that, “Hey, these diagnoses might exist. Do you agree?” And in order to move through the day, they say yes, but the diagnosis, maybe technically doesn’t meet Medicare guidelines, or doesn’t meet clinical guidelines. And that is not being audited, right? Yeah. And I don’t think that’s going to be very far off from when Medicare says, not only do you have to be compliant from a technical perspective and the pieces of your documentation, but Hey, the definition of the medical problem needs to be there.

Does the patient really actually have that diagnosis?

Levi Wiggins: So we published the white paper on RADV audits, but the principles from that should be just as applicable to provider groups. And I want to just touch on those. One thing. Our paper determined was the provider behavior is the first thing to fix. And that’s, that’s the education piece.

The next thing we, we determined was that proper documentation fixes nearly everything. You know, you mentioned that if you document something that isn’t, you know, maybe it was well-documented, but it wasn’t clinically accurate- that could spell trouble down the road, but right now, we just really need documentation to be on point.

The next thing we’ve determined is that without the proper tools in place, documentation is nearly impossible to get right. Another thing we did determine that certain codes get used erroneously more than others. 

That’s also a very large terrifying gun to the head of a business. Is there anything I missed any any big takeaways we want to make sure we’re sharing. 

Farshid Kazi MD: No. I think the whole process of auditing and checking is all limited by human capital.

Right? We don’t have enough hours in the day or people to help us check this, but as we enter into this next digital era of healthcare, where we’re in the midst, Technology can help you do that. Not only can you audit some sample size, but you can have good visibility to your entire patient chart and be able to say with full degree of confidence, that every chart that I’m documenting against has some type of technology or eye that’s been placed on it to make sure I’m compliant and making sure I’m not making a human error, which happens.

So utilizing technology to solve for some of the workflow gaps to solve for some of the knowledge gaps we’ll augment, not necessarily replace the strategies that are good compliant organization has. So making sure you build that in, and then having a clear safety net and allow people to be able to raise their hands, if they feel uncomfortable will be the key to making sure you’re compliant and then have, you know, you know, have good nights of sleep at the end because you’re know you’re doing everything right for the right reasons.

Need to learn HCC coding, and don’t want to sit through another lecture? Click below to demo the DoctusTech app.

Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.

We recently published a white paper on RADV audits and the importance of strict HCC compliance. A few weeks later, the Department of Justice announced a groundbreaking $90 million settlement with provider group Sutter Health. 

In what looks to be a significant change of direction in RADV audit strategies, the DOJ has prosecuted a physician group.

False Claims Act allegations include “mischarging the Medicare Advantage program” and deliberately failing to pay back known overpayments. As a result, Sutter has agreed to not only a large financial settlement, but also five years of increased scrutiny and audits. 

This settlement takes place only months after Sutter settled a much larger antitrust case with the state of California ($575MM according to Fierce Healthcare). For provider groups, this is more than a cautionary tale, it comes with a stern warning.

“Health care providers who flout the law need to know that my office will hold accountable those who pad their bottom line at taxpayer expense.” – Acting U.S. Attorney Stephanie M. Hinds

For a group as large as Sutter Health, the $90 million is not much. Sutter received $812 million in payouts from the CARES Act; $900+ million in advance Medicare payments; and last year banked $13 billion in revenue. So all dollars considered, this settlement represents a mere 0.7% of Sutter’s annual revenue. However, for the whistleblower who stands to receive up to a quarter of those funds for her work with the DOJ, this is more than significant, it is life-changing. And for potential future whistleblowers, this case is both a legal precedent and a strong financial motivator. 

And provider groups of all sizes need to take notice.

Much of the language in the DOJ’s press release reads more like a scolding than a legal case. As though The United States is not merely alleging financial misconduct, but expressing disappointment with the parties.

“The government alleged that Sutter Health knowingly submitted unsupported diagnosis codes for certain patient encounters for beneficiaries under its care. These unsupported diagnosis codes caused inflated payments to be made to the plans and Sutter Health. The lawsuit further alleged that, once Sutter Health became aware of these unsupported diagnosis codes, it failed to take sufficient corrective action to identify and delete additional unsupported diagnosis codes.”

In short, the DOJ alleges that Sutter deliberately coded unsupported diagnoses, got paid, knew about it, and didn’t pay back the overpayments.

“The government relies on healthcare providers, including those furnishing services to Medicare Part C beneficiaries, to submit accurate information to ensure proper payment… Today’s result sends a clear message that we will hold health care providers responsible if they knowingly provide or fail to correct information that is untruthful.” – Deputy Assistant Attorney General Sarah E. Harrington

No longer are RADV audits only a concern for payors, but providers will be held responsible for their HCC coding and the accuracy of their RAF scores.

“Today’s settlement exemplifies our commitment to fighting fraud in the Medicare program.” – Acting U.S. Attorney Stephanie M. Hinds for the Northern District of California.

From the tone of the DOJ’s own press release, this case is only the beginning. 

“The knowing submission of inaccurate information to Medicare diverts funds from this vital health care program, which is a disservice to patients needing care… We will continue to work with our law enforcement partners to protect the integrity of federal health care programs and hold accountable entities who engage in false claims practices.” – Special Agent in Charge Steven J. Ryan for the Office of Inspector General of the U.S. Department of Health and Human Services

This may be the first case of its kind, but if the DOJ is to be believed, this will not be the last. 

Also, as a condition of the settlement, no admission of wrongdoing has been made by Sutter Health and their affiliates.  “The claims resolved by the settlement are allegations only and there has been no determination of liability.”

DoctusTech co-founder and population health expert Dr. Farshid Kazi will dig deeper into the ramifications of this case, and share resources and methods for avoiding a similar fate on the next installment of Live With Dr. Kazi. 

Resources:

Read the DOJ’s full statement HERE.  

Access our HCC Quick Start Guide HERE.

Access the full white paper HERE.

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

Watch the full interview here!

Levi: All right, we are back with another episode of DoctusTech thought leadership with Dr. Kazi. Hey, Dr. Kazi, how you doing? 

Farshid Kazi, MD: Hey, Levi, doing well. 

Levi: Today, I want you to talk about how, value-based care is generally good for our nation, the United States of America. 

Farshid Kazi, MD: Yeah. The main thing people think about when it comes to healthcare is how do I one have lower premiums each month and have better outcomes.

But at a macro level, when we think about costs of care, that rises for a number of different reasons, but when it comes to value based care, you can solve both the personal side and the macro side. As long as we reinvest into taking care of our patients who are at risk for the highest chronic conditions, we’re going to do better as a country.

And a lot of that stems from giving patients choice and involvement in healthcare, which a hundred percent we stand behind. It doesn’t matter what field of medicine is. But sometimes having a clinician, that’s going to be able to spend a little bit more time to educate you, to teach you about the right definitions and what the decisions you have in front of you will allow you to make One) better decisions for yourself; but Two) more affordable decisions for the country.

And sometimes more is not better. And oftentimes when we think about your loved one, your grandma, your significant other even a child sometimes more is not better. That means tests, surgeries, exams, and a good clinician should be able to guide you through that. So from our country’s perspective, value-based care aligns incentives, performs better. And overall from a country’s perspective, you’ll have better outcomes. 

Levi: Okay, one thing we talk about in the industry is the quadruple aim. And it seems like that is something that the value-based care HCC world can almost in one shot solve. Can you, can you speak to that? 

Farshid Kazi, MD: Yeah. And I think we’ve broken this up nicely and some of the segments we’ve talked about already, right?

How do we make life better for your patients. So better care for individuals. How do we make a better care for all of the US, which is better population health and do that by lowering costs? I think sometimes the equation misses, and this is where quadruple aim comes in is how do we improve lives and balance for physicians?

So you have better care for patients, better care for the country at large or a population health perspective, better work-life balance for clinicians at lower cost. 

Levi: And how do we fix that? 

Farshid Kazi, MD: Yeah, I think you, you have to start with aligning incentives, right? And so when you think about the categorical shift, that payment happens through fee for service or your traditional model to value based care, where now clinicians are paid for outcomes.

All of a sudden you’ve aligned everything, patient outcomes to physician work-life balance, to lowering costs, and then better care for the population at large.

Need to learn HCC coding, and don’t want to sit through another lecture? Click below to demo the DoctusTech app.

Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.

Watch the full interview here!

Levi: Hey, Dr. Kazi, we’re back with another episode of doctors tech thought leadership.

So today we want to talk about. Value-based care, as it, as it relates to specifically benefits to the doctors, how is this good for you and your associates?

Yeah. I think as a provider, Levi, we in the fee for service world or the traditional sense of healthcare, get paid only when a patient can come in for a billable diagnosis.

I can have you come in because you’re sick, and bill the insurance company. They say, here you go, Dr. Kazi, which is great, but there’s so many aspects to keeping patients healthy that are not billing. Worrying about your diet, worrying about loneliness, worrying about your mental health.

And some of those components, I, as a clinician, wish I had either the time or the reimbursement to reinvest into your care. So as physicians are starting to transition into value-based care, They are now being reimbursed to care for their patient in a holistic way. And those are, I think, fundamentally the reasons all of us clinicians—it doesn’t matter what specialty you’re in—went into medicine, is how do I make sure that I make you healthier over time?

And so value-based care allows me to do that, which is quite relieving in, in many ways.

Levi: Now there’s, there’s the compassionate doctor side of the equation. And then there’s the aligned financial incentives side of the equation.

So as a physician owner, why is this good for you? Risk sounds risky. How does this work?

Dr. Kazi: Yeah. So everyone should not be taking risk upfront, which is a spot-on. It does sound risky, but if you want to practice medicine the way we all thought we would like to, when we were kids, value-based care is the right space to be in.

You don’t need to worry about the number of patients that you need to see every day. You need to worry about what their clinical outcomes are and by clinical outcomes, it means are they going to the hospital? Are they going to the ER, are they taking care of themselves? Preventatively?

And from a financial perspective, you’re getting a set run-rate on your revenue each year. So you don’t have to worry about how do I get my patients to come in, to see me. I’m rather getting a set budget that I can take care of my patient population.

And the ones that are sick and that you have a good relationship with, you’re going to be able to bring in more often than you would have been allowed in the traditional model.

So it helps you financially control your revenue. It helps you control your day to day. Decreases the burden of needing to see a ton of patients, which is why – number one reason people are burning out these days.

Levi: That makes sense. Okay. So at the risk of saying something that we would have to cut from this video later it seems like there’s potential financial upside for providers who enter into risk sharing contracts and code really accurately and document everything.

It seems to me that a doctor or practice could make more money and take better care of patients. Is that reasonable or is it, is it more profitable to just do fee for service?

Dr. Kazi: Yeah. It depends right? The clear answer is, it’s better to deliver good care and make profit, which is a hard thing to say.

And the traditional model, if you’re seeing 30, 40 patients a day, it’s really hard to stand by and say that you’re going to have better outcomes. And in fact, if you look at the data around. Patients that are in traditional Medicare versus patients who are Medicare advantage. They consistently outperform our quality metrics, meaning preventative screenings hospitalizations, total cost of care, which is just a reflection of outcomes on a clinical perspective.

So if you think about just where do you get your biggest bang for buck? It is on the value-based care side.

From a revenue perspective. Yes. If the doctor is taking better care of their patients, they will make more money, but that’s the right model of payment. Not necessarily just seeing more patients because you happen to be churning through a lot of sick patients.

Levi: That makes sense. And just to put a, put a little commercial break onto this: On average, what do we see from a DoctusTech perspective on increased reimbursements when coding is done correctly and recapture rates are at 95%, what does that look like per doctor, per year?

Dr. Kazi: And that could look… it depends on the contracts and they vary quite a bit, but you can look at five to six figures, per doctor per year, on top line revenue increase- if you’re just appropriately documenting.

And that’s, again, not talking about up-coding, we’re not talking about making sure you’re increasing a panel, but you should get paid for doing all the hard work you are.

And that is done through better documentation, which is where DoctusTech helps.

Need to learn HCC coding, and don’t want to sit through another lecture? Click below to demo the DoctusTech app.

Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.

One pillar of The Quadruple Aim is to Improve the clinician experience. 

Even before the COVID crisis, Physician Burnout has been a growing concern. And after 18 months of increased workload and stress, the problem is getting worse, not better.

The Joint Commission Journal on Quality and Patient Safety recently released a study on the relationship between cognitive task load and providers’ ability to perform their job well.

The short version: a 10% decrease in Physician Task Load (PTL) lowers the odds of experiencing burnout by 33%.

The specialties with the highest PTL score were emergency medicine, urology, anesthesiology, general surgery subspecialties, radiology, and internal medicine subspecialties.

It had been theorized that personal vulnerability could be at the root of the physician burnout crisis, but the data do not support this. The JCJQPS used cognitive theory and workload analysis to conduct cutting-edge research, and their findings are both compelling and academically rigorous.

“We evaluated the cognitive load of a clinical workday in a national sample of U.S. physicians and its relationship with burnout and professional satisfaction,”

– Elizabeth Harry, MD, SFHM, coauthor and Hospitalist at University of Colorado at Denver & Aurora

While the study did point to workload as the smoking gun quadruple-aimed at the heart of physician burnout, it did not shed much light on how to reduce that workload, and ease the bourdon of burnout. Several of the coauthors have more to say on that topic.

“Deeper evaluations could follow to identify specific potential solutions, particularly system-level approaches to alleviate PTL… In the short term, such analyses and solutions would have costs, but helping physicians work more optimally and with less chronic strain from excessive task load would save far more than these costs overall.”

– Dr. Colin P. West, Coauthor, Professor and Researcher at the Mayo Clinic.

At DoctusTech, we are eager improve all four pillars of the Quadruple Aim.

Like you, we believe that value-based care has the potential to be a massive lever to improve clinical outcomes, population health, cost and clinician experience. (Yes, VBC touches all points of the Quadruple Aim!)

We understand that embracing Value-Based Care can be a lot to take on, and at first, could potentially add to the Physician Task Load. This should not be the case – HCC coding can be learned in far superior ways than the tired conference room lecture  (or zoom call). What if learning HCC coding was fun, easy, and actually gave clinicians an opportunity to engage with learning in a manner that added energy to their day, rather than depleting it?

On the Clinician Experience front, both our learning app and our integrated platform help ease the workload and improve the quality of life for clinicians. Ask us how?

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

Need to learn HCC coding, and don’t want to sit through another lecture? Click below to demo the DoctusTech app.

Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.

Watch the full interview here!

Levi: On today’s episode of DoctusTech thought leadership, I want you to go in the weeds a little bit on the topic of HCC coding as it relates to value-based care – and how that is beneficial to patients. And I feel like this is one where I could just wind you up and send you running.

Dr. Kazi: Yeah. HCC coding such a dry topic, but I’m super passionate about it.

Only because it drives why I became a physician, right? And when we think about value based care, it’s such a big umbrella term. But in a very specific way, it’s really getting paid for providing better outcomes.

And when we were all training as physicians back in the eighties, nineties, and even early two thousands, it was about how many patients can you see a day, make sure you get them healthy and move them forward.

But now, value-based care is really paying us as docs to say, “Hey, here’s a subset of patients, take care of them. And if you can keep them healthy and out of the hospital, well, great. That’s profit in your back, your pocket. And if you can’t, then, you know, that’s risky.”

And so where HCC coding goes is, “Let me help appropriately document how sick my patient population is, so I get paid the proper amount!” And that’s not something any of us have been taught in med school. You’re taught how  to diagnose a medical problem. You’re taught how to treat it, but when it comes to how to document—and be compliant—and actually show the severity of illness of your patient population, none of us have been taught to do that.

So it’s critical in this new shift.

Levi: Okay. So tell me as… let’s say, “I’m Levi. I have COPD. Why does this matter to me, doc?”

Dr. Kazi: Yeah, so if you are in a value-based care arrangement, your doctor—i.e. me—I care about what your outcomes are. I don’t want to see you only when you’re sick. I want to see you when you’re healthy and make sure you stay on that trajectory so that we keep you healthy.

And we prevent bad things from happening in a couple of years, when maybe you haven’t been taking your medication because it made you feel tired and you didn’t tell me that. And so therefore in three years, I find out you haven’t been taking your medication for three years!

So let’s focus on building that relationship and keeping you healthy before any a catastrophic event happens.

Levi: We use the phrase a lot, “aligning incentives,” and the fee-for-service model aligns incentives, financially around treating you when you’re sick and, and there’s actually a financial upside to sick people. How does this flip the paradigm for the patient?

Dr. Kazi: You can’t get around it, money being the primary driver on how a lot of businesses run, and there’s no hiding that medicine is still a business. And as long as that’s the case, physicians are paid and reimbursed only when I can bill for it.

I can’t bill to have Levi come in and talk to me because he’s having a tough time affording his medications or having a side effects from it. And I wouldn’t know that without bringing you in to have that conversation. I would see you only when something happened to you, you couldn’t breathe. You feel bad. I need to send you to the hospital!

But now in value-based care, I can bring Levi in whenever I want, because I know he’s just going to need a little bit more love and attention as we start to understand what the barriers to your care delivery are.

And so this new model allows me that flexibility to bring in the patients who I want, even if they’re healthy, because I think it’s going to have a change in our trajectory.

Levi: This is a little off topic, but remote patient monitoring and tele-health seem like they’re ways to make that even easier.

Dr. Kazi: That’s right. And there are a lot of companies that are emerging out here that are helping doctors do a number of different things in value-based care, tele-health, remote patient monitoring are all new emerging fields, because the penetration of value-based care reimbursements have gotten to about 30%.

We expect that to go even higher in the next couple of decades where the majority of people of Medicare age will be in some kind of value-based care arrangement.

Levi: Okay. So just to make sure I’m capturing this as a patient, you are financially incentivized to keep me healthier, because if I’m sick, it actually costs more money to take care of me.

If you maintain my health, it costs less money and your practice is more profitable. So you want me healthy probably as much or more than I do.

Dr. Kazi: Absolutely. And the hope is that it’s equal, right? So it’s a joint partnership there, and it allows me the flexibility to do so.

Levi: Now HCC coding: we talk a lot about recapture rate.

So if, if I have COPD,  you have to diagnose that again next year in order to maintain that diagnosis. So you need some sort of a mechanism to do that. how does that serve me as the patient?

Dr. Kazi: So, if you forget the coding aspect to it, if you’re just thinking about it from a common sense perspective, you have COPD, you should probably be talking to your doctor about it at least once a year—if not more—saying, “How are things going?”

Any medical issues that you have that are chronic, that the government feels like they drive costs – we should be having a conversation. In fact, that’s a clinical decision that we should be making independent of the government. So as long as you and I are talking about it, it should be documented appropriately.

And that allows the government to say, “Yeah, Levi is at risk for clinical deterioration, but Dr. Kazi is doing the right things to care for him. And therefore here’s a pot of money that we want you to use to reinvest into, into Levi’s care!”

And that might be well visits. I might have a nurse call you just to check in with you. I might have just a, a best friend, who we call a care coordinator, check in with you and solve for loneliness. Make sure we look at your dietary constraints so that you’re not exacerbating some of your other diseases.

These are all ways that the government’s allowing me as a clinician and you as my partner, as a patient to think about where should we spend that money to keep you healthy and out of the hospital.

Need to learn HCC coding, and don’t want to sit through another lecture? Click below to demo the DoctusTech app.

Need better RAF scores and recapture rates in your practice? Demo the DoctusTech integrated tools, and learn how to make your value-based care contracts more profitable. Schedule a demo today.

Planning Ahead For Strict HCC Compliance Protocols

Key Findings From 400 RADV Audits, 2011-2021 

What is a RADV Audit?

The Medicare Risk Adjustment Validation Program (RADV) was created to identify and correct past improper payments to Medicare providers and implement procedures to help the Centers for Medicare & Medicaid Services (CMS), Medicare carriers, fiscal intermediaries, and Medicare Administrative Contractors (MACs) implement actions that will prevent future improper payments.

Simply put, it is a process whereby CMS validates payments and recoups over-payments.

How does it work?

CMS selects a statistically valid sample of members enrolled in an Affordable Care Act (ACA) compliant plan. Providers whose patients are selected for an audit receive requests and must provide copies of medical records.The audit seeks to verify that diagnosis codes, submitted on claims and reported to CMS, are accurate, properly documented, and coded with appropriate levels of specificity.

In accordance with the provisions of the Patient Protection and Affordable Care Act (PPACA) and its risk adjustment data validation standards, CMS then takes that statistical information and extrapolates from it the amount of overpayment that the health plan or billing entity is responsible for. In many cases this can range from several $100Ks to several $MMs.

Takeaway 1: Small errors return large chargebacks

Extrapolating from statistics based on errors yields significant sums.

In the three case studies referenced in the white paper, the overpayment ranged from 10% – 12% of total annual revenue. As a percentage of profit, that is a sizable number. While Einstein may have said that compound interest is the most powerful force on earth, we say that extrapolated overpayments are the most powerful force in ruining your year.

Takeaway 2: Some codes get misused more than others

These are the top three misused HCC codes from the audits data:

Takeaway 3: Provider behavior is the first thing to fix

While there are many ways to chase down diagnoses after the fact, the gold standard for HCC coding is at the point-of-care, right there with the patient. The opportunity for improvement in this stage has more to do with the tools that change behavior than the tools that chase data. Changing behavior is difficult, and the old-fashioned lecture approach to HCC learning is not likely to succeed.

Takeaway 4: Proper documentation fixes everything

Once the challenge of changing provider behavior has been tamed, the next beast lives inside the EMR. Whether you’re talking recapture rates or suspecting, there are significant financial risks in coding without proper documentation. Solutions that connect encounter data to HCC documentation to automate compliance are mission-critical for physician groups. These solutions will help groups provide top-quality care and protect them from negative RADV audits.

Takeaway 5: Without proper tools, documentation is daunting

At the risk of shameless self-promotion, we have enabled myriad providers with the tools to ensure the best possible outcome from a RADV audit. From capturing diagnoses at the point-of-care to ensuring documentation compliance — the DoctusTech family is ready for an audit. Our tools mean you are unlikely to be caught with your hand in the CMS cookie jar, and be put in the uncomfortable position of watching your revenue evaporate.

To learn more about how we prepare you for a RADV audit, help your providers improve HCC coding, and boost RAF accuracy by 30%, book some time with our HCC expert HERE.

Resources:

Access the full white paper here

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

HCC Quick Start Guide