In value-based care (VBC), accurate risk adjustment is more than just a compliance checkbox—it’s the foundation for proper reimbursement, better population health management, and meaningful patient care. But each year, many chronic conditions go undocumented, leading to missed revenue and underrepresented patient risk scores. The issue? Poor HCC recapture.

Let’s explore why this happens and how HCC recapture with AI support is revolutionizing the way healthcare organizations approach documentation, recapturing, and compliance.

Why HCC recapture falls apart

The reasons for poor HCC recapture are deeply tied to the organization’s level of sophistication and resources. For example, in practices with limited infrastructure, clinicians are often solely responsible for identifying and re-documenting HCCs—sometimes in real time during the patient visit—without additional support.

Let’s imagine a scenario: a primary care physician is reviewing a patient’s chart during an annual wellness visit. If the patient’s chronic conditions are clearly listed in the problem list and thoroughly documented in the past, the provider may be able to recapture some of those HCCs. But even then, the clock is ticking. 

They will prioritize an acute issue like elevated blood pressure in the limited time they have, skipping over less acute but still relevant diagnoses like diabetes or morbid obesity.

This leads to partial documentation. Worse, if last year’s documentation used a nonspecific diagnosis (e.g., “depression” instead of “major depressive disorder”), that HCC could be lost completely, along with a significant chunk of the RAF (Risk Adjustment Factor) score and associated revenue.

Even the most diligent clinicians can miss crucial diagnoses—not because they lack knowledge, but because the workflow isn’t built to support accurate and complete recapture. Let’s break down where traditional workflows make it even harder to get this right.

For example:

• • A provider may document “depression” multiple times, not realizing that CMS requires specificity (like “major depressive disorder”) for accurate risk capture.

• • A patient’s “heart failure” may be addressed during a visit. Still, if the encounter is documented solely under hypertension —a related condition that isn’t an HCC— the heart failure can go unrecaptured, despite being part of the clinical management.
    

All of this adds up to a system that puts too much pressure on clinicians and leaves too much room for error. The intention is there, but accurate HCC recapture becomes a hit-or-miss process without the right tools and support.

So, how do organizations try to catch what’s been missed? Let’s take a look at how manual chart reviews typically approach recapture.

How manual chart reviews typically handle recaptures

In many organizations, HCC identification is still handled manually, and while this method can catch missed diagnoses, it comes with significant limitations.

There are generally two approaches to manual chart reviews. 

In one, coders check completed notes after the visit and advise clinicians on which ICD-10 codes need further specificity to support accurate HCC documentation. 

In another, coders flag missed codes and offer clinical suggestions for future encounters. For example: “Based on this documentation, consider evaluating for [condition] at the next visit.” Both approaches can be valuable, but they rely on retrospective review.

And that’s where the problem begins.

Manual reviews are typically conducted after the note is signed, often 48 hours or more after the encounter. Due to this delay and the need to prioritize resource allocation, most organizations opt for targeted reviews, focusing only on specific visit types, such as annual wellness visits or charts flagged by payers. That means a large volume of documentation goes unchecked, leaving many conditions uncoded.

Even when organizations attempt broader reviews, staffing becomes a bottleneck, as it requires a large team of coders, either in-house or contracted, which drives up costs and slows down workflows. Most teams don’t have the bandwidth to do this consistently.

When documentation isn’t reviewed in time—or if it’s never reviewed at all—opportunities for accurate risk capture are missed. In some cases, entire panels of patients go under-coded for extended periods, leading to significant revenue loss and compliance risk. A provider with a large panel could potentially go an entire year without properly documenting HCCs. 

Even if the gap is identified, it will require dedicated chart review sessions to clean up the data. Even then, if it is identified months later, some notes might fall outside the permissible correction window, meaning the lost revenue cannot be recovered.

This kind of scenario isn’t rare. And in today’s value-based care environment, where timely, accurate recapturing directly affects both compliance and reimbursement, that’s no longer good enough.

Some organizations try to balance costs by outsourcing coding reviews, focusing only on annual wellness visits, or high-risk patients. But even then, many gaps go unnoticed until it’s too late.

That’s the fundamental issue with manual recapture: even with experienced coders and targeted strategies, it’s still a race against time, capacity, and documentation gaps. And when the process relies on people catching mistakes after the fact, it’s nearly impossible to scale, let alone catch everything.

But that’s precisely where AI changes the game.

Transforming HCC Recapture with AI: A Game Changer for VBC Organizations

Artificial intelligence fundamentally shifts the approach to HCC documentation. Unlike static, rules-based systems, AI analyzes language, patterns, and relationships across patient records. Here’s how HCC recapture with AI redefines the game:

1. Text interpretation, not just data matching

AI can understand free-text notes, detect nuanced language around diagnoses, and flag relevant conditions—even when the conditions have not been coded or listed in structured fields.

For example, if a patient has multiple mentions of fatigue, shortness of breath, and previous heart studies, AI can connect these elements and recommend evaluation for a likely heart failure diagnosis —even if the condition hasn’t been explicitly listed.

This level of insight is nearly impossible with hardcoded rules, which can’t account for the complexity and variation of clinical language.

2. Documentation feedback

DoctusTech’s AI Coding Agent reads progress notes in real time and delivers actionable documentation feedback  (for supported EMRs), and it checks 100% of charts for compliance, helping teams:

• • Recapture all previously documented HCCs.
  • Ensure documentation meets MEAT criteria.
  • Identify which conditions are compliant vs. at risk of audit failure.

By flagging errors, the AI agent boosts coder productivity up to 3x, supports compliance, and reduces RADV audit exposure.

3. Workflow-friendly support

AI doesn’t have to be disruptive. When integrated thoughtfully, it acts as a smart assistant:

• • Pre-visit: Surfaces suspected conditions for recapture
  • Point-of-care: Highlights relevant lab results, history, or prior notes tied to a flagged condition
  • Post-visit: Alerts providers to incomplete or non-specific documentation, with suggestions for improvement

Clinicians stay in control. AI simply directs their attention to the most relevant information—reducing the cognitive load without dictating care.

By shifting from reactive reviews to real-time, intelligent support, AI doesn’t just catch more—it empowers teams to document better from the start. But accurate documentation isn’t just about what gets flagged. It’s also about how well that documentation holds up under scrutiny.

That’s where MEAT criteria come in—and why they play a critical role in both recapture and compliance.

The role of MEAT in recapture and compliance

Recapture isn’t just about checking a box. CMS requires documentation to show that a provider is actively managing a chronic condition. That’s where MEAT criteria come in:

• • Monitor: e.g., symptoms, labs, tests.
  • Evaluate: e.g., progress, response to treatment.
  • Assess/address: e.g., ordering tests, adjusting medications.
  • Treat: e.g., prescribing drugs, recommending lifestyle changes.

AI can analyze the clinician’s note and determine if each component is present for a given diagnosis. If one is missing, it flags the documentation as non-compliant.

This not only protects against audits, but it also ensures that the diagnosis is medically justified and relevant to the patient’s ongoing care.

MEAT isn’t just a compliance checkbox—it’s an excellent standard for credible, defensible HCC coding. And when it’s missing, the consequences go beyond documentation errors.

By holding documentation to MEAT standards, organizations strengthen both compliance and care quality. But ensuring every note meets those standards—consistently and efficiently—is a challenge no one should tackle alone. That’s where AI steps in, not to replace clinicians or coders, but to work alongside them.

Let’s examine how AI can become a trusted partner for coders, scribes, and clinicians.

AI as a partner for coders, scribes, and clinicians

In an ideal system, AI tools act as intelligent assistants—not replacements—for coding teams that include clinicians, coders, and scribes. When it comes to HCC recapture, the goal is to create a seamless partnership where AI enhances accuracy and efficiency without overwhelming workflows.

For clinicians, AI should:

• • Flag relevant HCCs in real-time during the visit, prompting for specificity and completeness in documentation.
  • Surface relevant past documentation (e.g., specialist notes, diagnostic results) to support diagnosis without manual digging.
  • Act as a post-visit auditor, ensuring documentation meets coding requirements and identifying any missed opportunities.

For coders, AI should:

• • Triage cases based on complexity or risk of error, so coders can focus on the charts that need human review.
  • Reduce time spent reviewing accurate charts, improving overall efficiency.
  • Identify documentation discrepancies (e.g., incorrect use of active vs. historical conditions) that need human judgment.

For scribes, AI should:

• • Provide real-time prompts during documentation to ensure critical details are captured at the point of care.
  • Suggest structured language that aligns with coding and compliance standards—especially for HCC-relevant conditions.
  • Reduce the burden of manual chart navigation by pulling in key historical data or labs relevant to the visit.

Ultimately, AI should streamline—not disrupt—the workflows of clinicians, coders, and scribes. While it may introduce new tools or steps, it also removes bottlenecks, minimizes chart review fatigue, and improves the accuracy of HCC recapture. When done right, AI becomes a quiet but powerful ally in delivering compliant, high-quality documentation.

What to ask before choosing an AI vendor

If you’re evaluating an AI tool for HCC coding, one of the most important questions to ask is: “Is this system compliant with the most current CMS guidelines?” That means staying up to date with both ICD-10-CM updates and HCC model revisions—both of which are essential for accurate risk adjustment and compliance.

To evaluate a vendor’s system, here’s what to look for:

Ask the vendor:

• • When was the latest update for their ICD-10-CM and HCC model?
    • CMS typically releases updates in April and October each year.
    • If the system is still using ICD-10 data from more than 6–12 months ago, it may already be outdated.

Pro tip

• • Check a publicly available ICD-10 lookup tool (like the CDC’s), and verify that the Fiscal Year (FY) matches the current release.
    • For example, the FY2025 ICD-10-CM update includes April 1, 2025 Addenda—so that should be reflected in any up-to-date AI tool.

Check how the AI handles newer codes:

• • Choose a condition with recent coding changes (like Parkinson’s disease, which moved from a single code to subcategories like G20.A1, G20.B1, etc.).
• • Test the system: Input one of these newer codes. If the tool doesn’t recognize it, it’s likely not using the most current database.

If you’re unsure:

• • Go to CMS.gov and navigate to the ICD-10-CM and HCC model updates.
  • Cross-check the AI system’s output with the most recent agenda or code list to make sure it’s aligned.

Bottom line: A good AI vendor should be able to clearly explain their update schedule, provide transparency into the source of their coding logic, and respond to regulatory changes in real time. If they can’t? That’s a red flag.

But choosing the right vendor is just the beginning. When AI is thoughtfully integrated, it elevates every role—from clinician to coder—making HCC recapture more accurate, efficient, and sustainable. But the real impact goes beyond workflow improvements or audit protection.

Final thoughts: HCC Recapture with AI Isn’t Just Financial

The cost of poor HCC recapture isn’t just financial. It can delay diagnoses, skew patient risk profiles, and lead to failed audits. But the good news is that tools for HCC recapture with AI are no longer a futuristic dream. They’re here now—and they’re working.

Whether your organization is just starting or scaling a risk adjustment program, AI can offer support at every stage. From suspecting to MEAT compliance, it’s not about replacing clinicians—it’s about giving them back time, confidence, and accuracy.

And in value-based care, those three things are everything.

With AI-enhanced tools like DoctusTech, organizations can:

• • • Improve RAF accuracy
    • Streamline clinician workflows
    • Increase MEAT compliance
    • Reduce audit risk
    • Capture the full complexity of their patient population

Whether you’re just beginning your journey in risk adjustment or looking to optimize an existing program, AI is a critical advantage.

Want to see how AI can transform HCC recapture for your organization? Get a Demo to learn about DoctusTech today.

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.

Introduction

By 2025, the transition from HCC V24 to V28 will be complete. CMS has already begun a phased transition to the new model, but as we move into Q3, time is running out to prepare for 100% adoption. So what can organizations do to be ready for HCC V28? How can they remain compliant, ensure they’re correctly reimbursed, and that they continue to deliver exceptional patient outcomes under the new model? This short guide explains the essential next steps.

STEP 1: Understand the changes

Preparing for HCC V28 means teams must first understand the changes, and how they will affect their organizations. The following is a brief overview of the major differences between V24 and V28, but ongoing HCC coding education is critical if clinical and non-clinical staff are to understand their responsibilities in the new model.

• Demographic rates. Demographic factors including sex, age, disability status and dual eligibility status are weighted differently in HCC V28. In the new model, average rates will significantly decrease across most categories.
• HCC numbers. The total number of HCCs has increased in V28 – from 86 in V24 to 115 in the new model – while the total number of codes has fallen from 9,797 to 7,770.
• HCC groupings. CMS divides HCCs into 26 different condition ‘groupings’, and these groupings have changed significantly in V28. HCCs are coded, grouped and assigned differently – and staff will have to familiarize themselves with those changes.
• RAF modifiers. RAF modifiers including the Disease Interaction modifier and the Payment HCC Count modifier have also undergone changes between V24 and V28. The majority of interaction categories have seen their values reduced in the new model – with a couple of notable exceptions – while most Payment HCC Count modifiers have increased.
• Raw RAF adjustments. CMS’ backend RAF adjustment (the Normalization Factor) has been reduced in HCC V28, adjusting from 1.127 to 1.045.

This is just a topline summary of the changes between V24 and V28. For a deeper dive, check out our four-part series: Transitioning to HCC V28.

STEP 2: Assess reimbursement amounts 

The aforementioned changes will affect how each patient’s RAF score is calculated, and consequently, the amount organizations can expect to be reimbursed for their care. 

In HCC V28, RAF scores are likely to be a little lower than in the previous model – except for patients with multiple HCCs. However, every patient is different, and of course a number of factors influence how their RAF scores are calculated. 

While organizations can expect to receive slightly lower reimbursement amounts in V28, this won’t necessarily be true in every case. Medicare Advantage Organizations should calculate each patients’ adjusted RAF value to accurately determine reimbursement in the new model, and allow for reliable financial planning.

STEP 3: Ensure documentation accuracy

In HCC V28, many established HCC groupings, codes, and diagnoses have changed. New codes have been added, many old codes have been removed, and others have been combined or reclassified. In short, there’s a lot for clinical and non-clinical staff to re-learn. 

Maintaining documentation accuracy with a new set of rules and variables will prove a significant challenge for many organizations. Here are two approaches to maintain and improve documentation accuracy in HCC V28:

Continuous training and education

It’s widely accepted that HCC coding education is important to bring clinical and non-clinical staff up to speed with the documentation requirements of the CMS risk-adjustment model. However, traditional training methods result in knowledge retention rates of just 30% or less. With the new model taking effect, staff require continuous HCC coding education via a method that both engages them, and ensures lasting knowledge retention.

DoctusTech uses app-based learning to engage clinicians at 90%, with clinical vignettes and weekly questions offering up to 75% knowledge retention. Our app is up-to-date with HCC V28, and we even offer dedicated programs to help staff get to grips with the new model

Automated chart review

Automation can make it easier for clinicians to capture more accurate HCCs at the point of care. DoctusTech’s fully-integrated EMR workflow solution is an easier way for clinicians to accurately document HCCs on every patient, in their EMR of choice. Artificial intelligence allows us to automate the chart review process – helping clinicians translate patient charts into accurate HCCs in seconds.

If you’re concerned about the transition to HCC V28 and want to ensure continued compliance and documentation accuracy, DoctusTech can help. Schedule a demo today and find out how we can help your team prepare for V28.

HCC (Hierarchical condition category) coding is a complex and ever-changing field, and training clinicians in the traditional seminar format can cause significant pain points for healthcare providers and administrators. Here are just a few examples of the pain points that result from HCC coding education seminars:

Inaccurate or incomplete information: Traditional seminars often result in low retention, which leaves you with clinicians who may not provide accurate or complete documentation when coding for HCCs, which can lead to coding errors and non-compliance with CMS.

Difficulty applying the information: The seminars cannot provide hands-on training or clinical vignettes, which makes it difficult for attendees to apply the information they’ve learned in their own practice.

Lack of understanding of the most current guidelines: The seminars may not be up-to-date with the most recent guidelines and definition, which can lead to confusion and non-compliance.

Lack of ongoing education and support: The seminars cannot offer ongoing education or support, which makes it difficult for attendees to stay current with new information or retention.

Time and money wasted: Poor education seminars can be a waste of time and money – both for clinicians who attend them as well as the organizations that sponsor them.

Decrease in Reimbursements: Ineffective HCC coding education often leads to an increase in missed diagnoses and a decrease in revenue.

Audits and penalties: Bad HCC coding education often results in bad HCC coding, which can lead to an increased risk of audits and penalties from CMS.

Decrease in patient care: Bad HCC coding education can lead to an overall decrease in patient care, as providers may not be able to accurately diagnose and treat patients due to coding errors.

It is time for physician groups, hospitals and hospital systems to reevaluate the outdated methods of training clinicians on HCC coding and consider alternative options. While traditional HCC coding education seminars have been the norm for many years, they can be time-consuming, unengaging, and disruptive to the clinician’s daily workflow. Additionally, they simply are not as effective as other methods of training, which can lead to inaccuracies in coding and lost revenue for the practice.

Instead of relying solely on traditional HCC coding education seminars, physician groups should consider implementing a blended learning approach that combines different methods of training such as:

Online training modules: These can be accessed by clinicians at any time and can be tailored to their specific needs and experience level.

Self-paced learning: This allows clinicians to learn at their own pace and on their own schedule, reducing the disruption to their workflow.

One-to-one coaching: This can be done by pairing experienced coders with less experienced clinicians to provide real-world training and hands-on experience.

Using software such as the DoctusTech HCC coding education platform provides active education that helps clinicians engage with coding best practices, tests to run, things to look for, and ways to diagnose for risk in a Value-Based Care arrangement, helping to reduce the risk of audit penalties and fines.

Incorporating a blended learning approach can make training more efficient, effective, and engaging for clinicians, which can ultimately lead to improved coding accuracy, increased revenue for the practice, and reduced clinician burnout.

It’s also important to note that, even with the implementation of a blended learning approach, it’s important to have a mechanism in place to keep the clinicians accountable, so administrators know when and for whom a little extra one-to-one coaching and chart review could be beneficial.

Want to see the DoctusTech app in action? Schedule a demonstration today.

A CMS Medicare Advantage audit is a process used by the Centers for Medicare and Medicaid Services (CMS) to ensure that Medicare Advantage (MA) plans, also known as Medicare Part C, are complying with regulations and standards set by the CMS. The process includes several stages, including notification of the audit, preparation, on-site review, audit findings, and potential repayment or appeals.

Here’s a general overview of what to expect during a CMS audit:

1. Notification of Audit: The provider will be notified by the CMS of the audit, and will be given a specific timeframe in which to prepare for the audit.
2. Preparation: The provider should review their billing and medical records to ensure they are accurate and in compliance with government regulations. They should also review the CMS audit protocol and gather any supporting documentation that may be needed during the audit.
3. On-site Audit: A CMS representative will conduct an on-site audit of the provider’s billing and medical records. The audit may last several days, and the provider should be prepared to answer any questions and provide any necessary documentation.
4. Audit Findings: After the audit, the CMS representative will provide a report of their findings. If any errors or discrepancies are found, the provider will be given an opportunity to correct them.
5. Payment Recoupment: If the audit finds that the provider has overbilled the government, they may be required to repay the overbilled amount.
6. Appeals: If the provider disagrees with the audit findings, they have the right to appeal the decision.

It is important to note that the CMS audit process can be stressful and time-consuming, but by following the guidelines and providing accurate and complete information, providers can minimize their risk of overpayment recoupment and negative findings.

It’s always a good idea to be proactive and conduct regular internal reviews and compliance audits to identify and correct any errors or non-compliance issues before an official CMS audit takes place.

In summary, a CMS audit is a process used by the government to ensure that healthcare providers and suppliers are complying with Medicare and Medicaid regulations. During an audit, a CMS representative will review a provider’s billing and medical records to ensure they are accurate and in compliance with government regulations. Providers should be prepared to answer any questions and provide any necessary documentation.

As a healthcare provider, it’s essential to understand the importance of accurate HCC (Hierarchical Condition Category) coding. HCC codes are used to classify patient conditions, which determines  Medicare Advantage payments. Inaccurate HCC coding can have serious consequences for both your practice and your patients.

Inaccurate HCC Coding Impacts Revenue

One of the most significant risks of inaccurate HCC coding is financial loss. When codes are not reported correctly, the capitated payments for your patient care will be lower than they should be. This can have a significant impact on the bottom line of your practice, and it can be difficult to recover lost revenue. Furthermore, practices may also be subject to audits or investigations if it is found that they have submitted inaccurate codes. These can be costly and time-consuming, and often result in fines and penalties.

Inaccurate HCC Coding Impacts Patient Care

Inaccurate HCC coding can also negatively impact the care that your patients receive. The codes are used to identify patients who have complex health conditions, and when codes are not reported accurately, these patients may not receive the additional resources they need. This can result in poorer health outcomes and increased healthcare costs down the line.

Inaccurate HCC Coding Impacts Compliance

Another major risk of inaccurate HCC coding is compliance. If your healthcare providers are not be aware of the latest coding guidelines and regulations, that can lead to coding errors. Inaccurate coding can result in compliance violations and non-compliance with laws and regulations can result in penalties and legal issues.

Inaccurate HCC Coding Is Not Mandatory

In order to mitigate these risks, it’s essential that healthcare providers  are trained and stay up-to-date with HCC coding guidelines and regulations. Your organization already invests in education and training for your staff, and you likely use coders and coding software that can help identify coding errors and ensure compliance. But this is not enough.

Fix Inaccurate HCC Coding With DoctusTech

The DoctusTech HCC coding education app is not only the best way to train clinicians, it is also the only way to measure your clinicians’  HCC coding knowledge while they learn. Training in our app helps providers to ensure that they are accurately diagnosing coding patient conditions and maximizing reimbursement.

Mitigate The Impacts Of Inaccurate HCC Coding

Accurate HCC coding is vital for the financial success of your practice, and for ensuring that your patients receive the care they need. Investing in training that really works and using technology tools to help you stay compliant can help you to mitigate the risks of inaccurate HCC coding.

Learn more about the DoctusTech app trains clinicians on more than which code to pick – it teaches them what to look for, what to test, and how to document for RISK in a Value-Based Care arrangement, to ensure that every HCC category is captured and every patient receives care for every condition. And because it is in an app, clinicians can do their training whenever and wherever, in just five minutes a week. And admins have total visibility into clinician engagement, learning progress, retention and growth, so your team will know which clinicians need a little extra coaching.

Stop Missing Diagnoses and HCC Categories

Do you want to stop missing HCC codes, categories and diagnoses? Schedule a demonstration of the DoctusTech app and start on the path to success in VBC. Schedule your demonstration here.

Here is the cheat sheet you’re looking for: DOWNLOAD 

ICD-10 codes are hard. Knowing which codes to use for Risk Adjustment in your Value-Based Care is even harder. And even the best available clinician training rarely yields lasting behavior change. Your team needs a resource in your pocket, but a cheat sheet isn’t the best available. 

A cheat sheet for ICD-10 codes can include a list of the codes and their descriptions, as well as common scenarios and the corresponding codes that should be used. 

Having a cheat sheet can also help you quickly look up any unfamiliar codes so that you can make sure you are using the correct ones. Some cheat sheets may even include helpful tips on how to use the codes, which can be very useful for those who are just learning about ICD-10 coding. 

So, if you are dealing with ICD-10 codes, having a cheat sheet can be a great way to stay organized and make sure you are using the correct codes.

Is it a cheat sheet if it helps provide better care to patients?

Absolutely not! First of all, it can help streamline the process of coding diagnoses and treatments. By having an easily accessible reference guide for ICD-10 codes, healthcare providers and coders can quickly look up the correct codes for their documentation. This saves time and can help ensure that all pertinent information is accurately and properly coded.

Secondly, an ICD-10 code cheat sheet can help to improve accuracy in medical coding. Medical coding is a complex process, and mistakes can be costly. An ICD-10 code cheat sheet can provide coders with a quick reference to ensure that they are using the correct codes for diagnoses and treatments. This can help reduce errors and improve patient care by ensuring that all relevant information is accurately and properly coded.

Finally, an ICD-10 code cheat sheet can help ensure that all necessary information is documented in a timely manner. By having a handy reference guide for ICD-10 codes, healthcare providers and coders can ensure that all necessary information is recorded quickly and accurately. This can help speed up the process of providing care to patients and ensure that their records are up to date.

In summary, an ICD-10 code cheat sheet can be a valuable tool for providing better care to patients. It can help streamline the process of coding diagnoses and treatments, improve accuracy in medical coding, and ensure that all necessary information is documented in a timely manner.

Why are so many clinicians searching for a cheat sheet?

ICD-10 codes are extremely complex and can be difficult to keep track of, and everyone wants to make their jobs easier and accurate. Clinicians too are often looking for quick and easy ways to access the codes they need quickly and easily. A ICD-10 code cheat sheet is a great way to do this. 

For example, there may be codes related to infectious diseases, cardiovascular diseases, etc. This cheat sheet allows clinicians to quickly find the code they need without having to search through a long list of codes. 

The other advantage of a ICD-10 code cheat sheet is that it can be used to check for accuracy. If a clinician suspects that a code might not be correct, they can quickly refer to the cheat sheet to double-check the code before submitting it for billing purposes. This helps ensure that the code is accurate and helps avoid any issues with billing. 

Get your ICD-10 code cheat sheet now!

Here are two simple resources that you can use to quickly and efficiently locate and select the most appropriate ICD-10 code when diagnosing chronic conditions for patients in a risk arrangement.

The DoctusTech HCC Quick Guide: A simple PDF with the HCC codes for the most frequently diagnosed conditions. 

The DoctusTech App – the best code finding lookup tool for VBC, complete with insights on connected conditions and proper documentation requirements.

As a healthcare provider, you know the importance of accurately and consistently documenting diagnoses, but not just to align revenue – there is a far greater reason for specific, accurate HCC coding: patient care. One thing that is often overlooked when calculating RAF scores is the simple fact that Risk Adjustment Factor is the simplest way to track a patient’s critical health: how difficult will it be to keep this patient alive? 

If you consider the RAF as an indicator of the life of your patient, and your patient population, then properly diagnosing, documenting, and calculating RAF makes a lot more sense. This simple number tells a complex story, and it is vital to the health and lives of your patients – which is why proper HCC documentation is critical, and having instant access to the right HCC code is of utmost importance. 

One way that many clinicians have traditionally done this is by using HCC (Hierarchical Condition Category) coding cheat sheets. These sheets provide a list of diagnoses and the corresponding HCC codes, making it easy for clinicians to find the right code for a particular diagnosis.

While HCC coding cheat sheets can be useful in the short term, relying on them too heavily can lead to problems in the long run. Here are a few reasons why you may want to consider weaning your clinicians off of HCC coding cheat sheets:

Cheat sheets can be outdated: HCC codes change frequently, and cheat sheets may not always be updated to reflect the most current codes. This can lead to incorrect coding, which can result in denied claims or underpayment.

Cheat sheets can promote a lack of understanding: Clinicians who rely heavily on cheat sheets may not take the time to fully understand how HCC coding works. This can lead to errors in coding and a lack of confidence in their coding abilities.

Cheat sheets can be a crutch: It’s important for clinicians to be able to code diagnoses accurately without relying on cheat sheets. This requires a strong understanding of HCC coding and the ability to think critically about how to code different diagnoses.

So, how can you wean your clinicians off of HCC coding cheat sheets? Here are a few suggestions:

Provide enhanced training: Consider offering HCC coding training to your clinicians to help them understand the coding process and develop their coding skills. This can be done through in-person training sessions or online courses.

Encourage critical thinking: Encourage your clinicians to think critically about how to code diagnoses and to use resources like official coding guidelines and the ICD-10 manual to help them determine the correct codes.

Use coding software: Many electronic health record (EHR) systems have built-in coding tools that can help clinicians determine the correct codes for diagnoses. Encourage your clinicians to use these tools to help them become more confident and accurate in their coding.

By taking these steps, you can help your clinicians develop strong coding skills and break their reliance on HCC coding cheat sheets. This will lead to more accurate coding, better reimbursement, and improved patient care.

We get it, HCC coding is hard: choosing the right HCC is nuanced, and can seem subjective. But when you see a patient, you are probably not reaching for a cheat sheet on how to diagnose this patient, right? How is it that HCC coding sent you searching for a cheat sheet?

And learning another new thing is hard, especially when the connection between caring for your patients and coding for VBC can seem tenuous at best. (It’s not, we promise.)

It is possible that the training you have received around HCC coding was not great. Learning HCC coding for VBC in a seminar is almost impossible – and the last several years of zoom seminars has exacerbated an already bad situation. Do you get emails with certain codes to focus on – the “Code of the Month Club” or the like? Do you occasionally get one-on-one coaching and chart reviews, but it is infrequent and perhaps does not match your learning style?

Knowing which code to use when diagnosing is nuanced, and the rules around HCC coding are very strict. Practicing medicine is an art, but the hard edges of HCC coding compliance and rigorous documentation are a very strict science. Less art, more math. And nobody went to medical school because they love math. And most of all, when you are moving fast to get to your patients, the last thing you want to do is dig for a code that is only meaningful for the billing department, and has very little bearing on how you treat your patients. 

Strategies on how to diagnose and document for VBC are not clear. It can seem like you are practicing coding and not medicine. But there is a deep truth in HCC coding that is often not communicated in training: diagnosing for risk is one of the most important steps in caring for your patients. 

Diagnosing for risk is a vital step in caring for your patients, and it has nothing to do with revenue. When CMS determines the guidelines around risk, a very simple metric is often overlooked: risk is just another way to say “how likely is it that this disease will kill my patient?” Risk Scores, Risk Adjustment Factors, the hierarchies within Hierarchical Condition Category coding – these are all just means of determining how dangerous and serious a condition is, and that should help you prioritize and treat your patients better, with better outcomes. And, to put it simply, better survival rates for your patients. 

HCC coding for Risk is just a data-centric approach to prioritizing care for your patients. Better care for the individual patient, because you captured every relevant diagnosis code, documented and planned care around those diagnoses. Better care for your entire panel, because you know the weighted risk of each patient, and can prioritize accordingly. And better care for your organization, because resources are available to provide care where it is needed most. 

But again, coding and documentation are daunting, and can seem insurmountable – hence, the need for a cheat sheet.

But what if we told you that there was hope for this situation? A brighter day is coming. 

Somewhere on your team, somebody is evaluating the DoctusTech HCC Coding education app, which was designed by doctors to help you master diagnosing for VBC in a fun and engaging app. And after the initial evaluation, it only takes about 5 minutes a week to achieve full HCC coding mastery. And the best part is that it’s not only NOT BORING, it’s actually engaging, competitive, and please verify this – FUN. 

If nobody on your team is evaluating the DoctusTech app, somebody’s got to do it. If that’s you, great – download it here, and book some time with our team to see it in action. If there’s somebody you think should be evaluating the DT app, please share it with them, they will thank you. 

Fred Schulte, Kaiser Health News and Holly Hacker
Republished with permission

Newly released federal audits reveal widespread overcharges and other errors in payments to Medicare Advantage health plans for seniors, with some plans overbilling the government more than $1,000 per patient a year on average.

Audits — Hidden Until Now — Reveal Millions in Medicare Advantage Overcharges

Summaries of the 90 audits, which examined billings from 2011 through 2013 and are the most recent reviews completed, were obtained exclusively by KHN through a three-year Freedom of Information Act lawsuit, which was settled in late September.

The government’s audits uncovered about $12 million in net overpayments for the care of 18,090 patients sampled, though the actual losses to taxpayers are likely much higher. Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by major insurance companies.

Officials at the Centers for Medicare & Medicaid Services have said they intend to extrapolate the payment error rates from those samples across the total membership of each plan — and recoup an estimated $650 million as a result.

But after nearly a decade, that has yet to happen. CMS was set to unveil a final extrapolation rule Nov. 1 but put that decision off until February.

Ted Doolittle, a former deputy director of CMS’ Center for Program Integrity, which oversees Medicare’s efforts to fight fraud and billing abuse, said the agency has failed to hold Medicare Advantage plans accountable. “I think CMS fell down on the job on this,” said Doolittle, now the health care advocate for the state of Connecticut.

Doolittle said CMS appears to be “carrying water” for the insurance industry, which is “making money hand over fist” off Medicare Advantage. “From the outside, it seems pretty smelly,” he said.

In an email response to written questions posed by KHN, Dara Corrigan, a CMS deputy administrator, said the agency hasn’t told health plans how much they owe because the calculations “have not been finalized.”

Corrigan declined to say when the agency would finish its work. “We have a fiduciary and statutory duty to address improper payments in all of our programs,” she said.

The 90 audits are the only ones CMS has completed over the past decade, a time when Medicare Advantage has grown explosively. Enrollment in the plans more than doubled during that period, passing 28 million in 2022, at a cost to the government of $427 billion.

Seventy-one of the 90 audits uncovered net overpayments, which topped $1,000 per patient on average in 23 audits, according to the government’s records. Humana, one of the largest Medicare Advantage sponsors, had overpayments exceeding that $1,000 average in 10 of 11 audits, according to the records.

CMS paid the remaining plans too little on average, anywhere from $8 to $773 per patient.

Auditors flag overpayments when a patient’s records fail to document that the person had the medical condition the government paid the health plan to treat, or if medical reviewers judge the illness is less severe than claimed.

That happened on average for just over 20% of medical conditions examined over the three-year period; rates of unconfirmed diseases were higher in some plans.

As Medicare Advantage’s popularity among seniors has grown, CMS has fought to keep its audit procedures, and the mounting losses to the government, largely under wraps.

That approach has frustrated both the industry, which has blasted the audit process as “fatally flawed” and hopes to torpedo it, and Medicare advocates, who worry some insurers are getting away with ripping off the government.

“At the end of the day, it’s taxpayer dollars that were spent,” said David Lipschutz, a senior policy attorney with the Center for Medicare Advocacy. “The public deserves more information about that.”

At least three parties, including KHN, have sued CMS under the Freedom of Information Act to shake loose details about the overpayment audits, which CMS calls Risk Adjustment Data Validation, or RADV.

In one case, CMS charged a law firm an advance search fee of $120,000 and then provided next to nothing in return, according to court filings. The law firm filed suit last year, and the case is pending in federal court in Washington, D.C.

KHN sued CMS in September 2019 after the agency failed to respond to a FOIA request for the audits. Under the settlement, CMS agreed to hand over the audit summaries and other documents and pay $63,000 in legal fees to Davis Wright Tremaine, the law firm that represented KHN. CMS did not admit to wrongfully withholding the records.

High Coders

Most of the audited plans fell into what CMS calls a “high coding intensity group.” That means they were among the most aggressive in seeking extra payments for patients they claimed were sicker than average. The government pays the health plans using a formula called a “risk score” that is supposed to render higher rates for sicker patients and lower ones for healthier ones.

But often medical records supplied by the health plans failed to support those claims. Unsupported conditions ranged from diabetes to congestive heart failure.

Overall, average overpayments to health plans ranged from a low of $10 to a high of $5,888 per patient collected by Touchstone Health HMO, a New York health plan whose contract was terminated “by mutual consent” in 2015, according to CMS records.

Most of the audited health plans had 10,000 members or more, which sharply boosts the overpayment amount when the rates are extrapolated.

In all, the plans received $22.5 million in overpayments, though these were offset by underpayments of $10.5 million.

Auditors scrutinize 30 contracts a year, a small sample of about 1,000 Medicare Advantage contracts nationwide.

UnitedHealthcare and Humana, the two biggest Medicare Advantage insurers, accounted for 26 of the 90 contract audits over the three years.

Eight audits of UnitedHealthcare plans found overpayments, while seven others found the government had underpaid.

UnitedHealthcare spokesperson Heather Soule said the company welcomes “the program oversight that RADV audits provide.” But she said the audit process needs to compare Medicare Advantage to original Medicare to provide a “complete picture” of overpayments. “Three years ago we made a recommendation to CMS suggesting that they conduct RADV audits on every plan, every year,” Soule said.

Humana’s 11 audits with overpayments included plans in Florida and Puerto Rico that CMS had audited twice in three years.

The Florida Humana plan also was the target of an unrelated audit in April 2021 by the Health and Human Services inspector general. That audit, which covered billings in 2015, concluded Humana improperly collected nearly $200 million that year by overstating how sick some patients were. Officials have yet to recoup any of that money, either.

In an email, Humana spokesperson Jahna Lindsay-Jones called the CMS audit findings “preliminary” and noted they were based on a sampling of years-old claims.

“While we continue to have substantive concerns with how CMS audits are conducted, Humana remains committed to working closely with regulators to improve the Medicare Advantage program in ways that increase seniors’ access to high-quality, lower cost care,” she wrote.

Billing Showdown

Results of the 90 audits, though years old, mirror more recent findings of a slew of other government reports and whistleblower lawsuits alleging that Medicare Advantage plans routinely have inflated patient risk scores to overcharge the government by billions of dollars.

Brian Murphy, an expert in medical record documentation, said collectively the reviews show that the problem is “absolutely endemic” in the industry.

Auditors are finding the same inflated charges “over and over again,” he said, adding: “I don’t think there is enough oversight.”

When it comes to getting money back from the health plans, extrapolation is the big sticking point.

Although extrapolation is routinely used as a tool in most Medicare audits, CMS officials have never applied it to Medicare Advantage audits because of fierce opposition from the insurance industry.

“While this data is more than a decade old, more recent research demonstrates Medicare Advantage’s affordability and responsible stewardship of Medicare dollars,” said Mary Beth Donahue, president of the Better Medicare Alliance, a group that advocates for Medicare Advantage. She said the industry “delivers better care and better outcomes” for patients.

But critics argue that CMS audits only a tiny percentage of Medicare Advantage contracts nationwide and should do more to protect tax dollars.

Doolittle, the former CMS official, said the agency needs to “start keeping up with the times and doing these audits on an annual basis and extrapolating the results.”

But Kathy Poppitt, a Texas health care attorney, questioned the fairness of demanding huge refunds from insurers so many years later. “The health plans are going to fight tooth and nail and not make this easy for CMS,” she said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Republished with permission from KHN

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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

And just the other day, we had just such a juicy morsel of intel shared internally, securely. And upon threat of death, we were told that we must not, in any way, share said information. 

And let me tell you, it was a whopper. The Big Kahuna. The White Whale of case study fodder. 

And as a member of our marketing team, let me just take a moment of personal privilege here to state emphatically THIS IS TOO GOOD NOT TO SHARE.

As The Man in Black once famously said, “But if there can be no arrangement, then we are at an impasse.” 

And that’s where we are. We are at an HCC coding, recapture rate, value-based care, patient outcome boosting, revenue improving, data-backed customer case study impasse.

So, just to set the table for you, please know that this is the kind of client results data that, were you to see it, your immediate thought would be, “Golly, I want these results for my organization!” And then your next impulse would be to double-quick DOUBLE-click on the button labeled [Book A Demo] and hastily pick the first time slot available.

And your next move would be to share the source of your joy with your Chief Medical Officer, your Chief Technology Officer, your CFO, CEO, CXO. And from there, you would set ablaze the slack channels, email and maybe fire off a text or two. 

And this is what you’d say:

“Team, these are the kind of results we need – and this is the tool we need to get us those results. This right here, DoctusTech has done it, and here’s the proprietary customer data from a recognized and well-respected name in the industry to back it up. And while they’ve tried to obscure the source, I’ve determined that it’s most likely [REDACTED]! Let’s jump on a demo right away, and get those same results for our org, ASAP!” (I paraphrase.)

And once the dust settled, and your demo was booked, and you shared just what prompted you to hastily beat down our digital door, I would be promptly hung by the ears. And the client who so graciously shared the impact our tools had on patient outcomes and their organizational bottom line would then set about hanging others by their respective ears and I would be out looking for gainful employment as a freelance beachcomber or plumber’s assistant. It would not be pretty.

So, to avoid all that unpleasantness, I’ve cut a little deeper into the specifics, redacting the customer-identifying data, obscured the actual data, and generalized the metrics to ensure that no client trust is being compromised. But at the same time, YOU, Healthcare Executive, are able to get the general gist of the compelling client data without risk to anyone’s ears or careers.

Here, without further ado, is the anonymized case study data from a highly respected name in the VBC space. 

As you can see, you will need to use a little imagination to apply meaning to the data points, as it relates to your particular organization and the impact DoctusTech will have on your numbers. Whether it’s an increase in RAF accuracy, unique code capture, recapture rates, clinician fund of knowledge on HCC coding, RADV audit preparedness, accountability, patient care, improved diagnostic specificity, decreased clinician workload (invert graph) or improved team spirit, you can clearly see that the impact would be significant. 

For further clarification and a demonstration, please do not hesitate to energetically and immediately click here to schedule that conversation with our team.

Revenue cycle management (RCM) is a hot topic this year. Monitoring, analyzing and improving the efficiency of your organization’s revenue processes is top of mind for leaders across many healthcare organizations. And you’ are probably still reading because you know that improving your organization’s revenue processes is essential to its success. But are you doing everything you can to implement a robust RCM strategy? Your competitors will not sit back and watch you take the lead. If you do not take action now, your competitors will leapfrog you with efficiency and better margins. . Read on for five ways that a strong RCM strategy will help improve your organization and drive financial success.

Build Strong Relationships with Partners

Revenue cycle management starts with strong relationships with your partners. This is especially true for organizations that rely on managed services or outsourcing partners to complete some or all of their revenue cycle activities. A strong partnership with your managed services providers will increase the likelihood that they will help you achieve your revenue goals. 

Partners are crucial to your success, so you must work to build strong partnerships with them. How can you do that? First, decide how your organization will work with partners. Then, clearly communicate that decision to all partners with which your organization does business. Strong relationships with partners will help drive success in all other areas of revenue cycle management.

Improve Customer Experience

One of the best ways to improve your customer experience is through managed services. Providers of managed services can handle many customer-facing activities, such as claims processing, that your organization might struggle to handle on its own. Doing so will free up your staff to spend more time on strategic revenue-generating activities. Strong relationships with managed services providers are also essential for ensuring that clients receive a quality experience. If managed services providers are not communicating with your clients in a helpful, empathetic way, your organization’s reputation will suffer. You can avoid these problems by clearly communicating with managed services providers regarding your company’s communication strategies and expectations.

Improve Diagnostic Accuracy and Specificity

One of the fastest pathways to improving revenue is to repair broken methods of diagnosing chronic conditions in risk contracts. Diagnosing very specifically, HCC coding correctly and documenting very accurately can provide not only a direct boost to revenue, but improves outcomes in patient care. HCC coding is vital to successful risk contracts, so RCM requires your organization to improve the actual fund of knowledge within your individual team members. If your organization is educating clinicians in seminars or zoom calls, emails and PDFs, you are missing out on the opportunity to improve diagnostic specificity and accuracy. And while accurately diagnosing can improve patient care revenue, inaccurate HCC coding can have dire consequences on your org’s bottom line. 

You might be hesitant to overhaul your HCC coding education, because it feels like a lot of work. However, it is far less of an organizational lift to improve training than it is to audit and fix errors along the way. And while some may claim that the new app-based HCC coding education is far less expensive than traditional training strategies, the real impact to revenue is cash flow positive. And that cost must be benchmarked against the inevitability of audits and repayments. Choose a partner you can trust to improve your team’s HCC coding, and see a direct impact to revenue, and simplification of the entire RCM process.

Monitor and Measure Key Performance Indicators

Management guru Peter Drucker once said, “Only what gets measured gets managed.“ No matter which areas of your revenue cycle you decide to focus on, you must monitor and measure your progress. This is critical for assessing the impact of your efforts and identifying areas where you might need to make changes. You can use metrics to measure customer experience, revenue cycle time, productivity, expenses and more. Choose the metrics that will help guide your RCM strategy the most. For example, customer retention and customer satisfaction metrics will be helpful for an organization that offers customer-facing products or services. RCM metrics that track the efficiency of your revenue cycle are also helpful for organizations that sell products and services. For example, tracking net revenue per customer and average revenue per customer over time can help you determine how well your revenue cycle is performing.

Automate Proven Processes

One of the easiest ways to improve your revenue cycle management strategy is to automate proven processes. If your organization is managing customer information, claims, billing or some other process manually, you are missing out on the opportunity to improve the process and save time and money. You might be hesitant to automate certain processes because you aren’t sure how they will work or if they will produce accurate results. If so, start small. Choose one process that you are confident will work as intended. Then, put the process into action. If it works as expected, implement it in other areas of your organization. If it does not work as planned, do not be afraid to scrap it and try something else.

Conclusion

Revenue cycle management is an essential strategy for all organizations. You cannot sit back and hope your revenue processes will improve on its own. It is the nature of RCM to get worse the moment you look away. You must take action to ensure that your organization is managing its revenue cycle as efficiently as possible. To succeed, you must work to build strong relationships with partners, improve your customer experience, improve diagnostic specificity and accuracy, monitor and measure key performance indicators, and automate proven processes. If you do, your revenue cycle management strategy will be strong and successful.

Check out our website doctustech

In a move that surprised very few in healthcare—and fewer on Capitol Hill—SCOTUS refused to hear UnitedHealth’s case against the 2014 Medicare Advantage Overpayment Rule. In the case of UNITEDHEALTHCARE CO., ET AL. V. BECERRA, SEC. OF H&HS, ET AL. the lower court’s ruling stands.

Back in 2018, a Fierce Healthcare headline announced, “Federal court nixes CMS overpayment rule, handing a big win to Medicare Advantage insurers.” 

“U.S. District Judge Rosemary Collyer in D.C. sided with UnitedHealth, which argued the rule that requires MA plans to return overpayments based on an analysis of its members’ health status was ‘wholly inconsistent’ with Medicare fee-for-service requirements.” 

And earlier in that same year, Fierce reported that, “DOJ abandons much of its Medicare Advantage fraud suit against UnitedHealth.” 

For a brief moment, it looked like Medicare Advantage insurers might not be legally required to “return overpayments based on incorrect diagnoses to CMS within 60 days of identifying them.” Ethical questions aside, it looked like they just might get away with submitting invalid diagnoses, getting paid, and keeping the money.

Unfortunately for MA plans everywhere, that big win was predictably followed by an even bigger appeal. And this time, documentation, accuracy, specificity and accountability won big. 

From the UnitedHealthcare Ins. Co. v. Becerra, United States Court of Appeals, District of Columbia Circuit, Aug 13, 2021:

The Overpayment Rule is part of the government’s ongoing effort to trim unnecessary costs from the Medicare Advantage program. Neither Congress nor CMS has ever treated an unsupported diagnosis for a beneficiary as valid grounds for payment to a Medicare Advantage insurer. Consistent with that approach, the Overpayment Rule requires that, if an insurer learns a diagnosis it submitted to CMS for payment lacks support in the beneficiary’s medical record, the insurer must refund that payment within sixty days. The Rule couldn’t be simpler. But understanding UnitedHealth’s challenge requires a bit of context.

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

The bottom line on The Medicare Advantage Overpayment Rule:

The Medicare Advantage Overpayment Rule has been weighed, measured and—for the time being—left standing, perhaps more firmly than before.

For greater context, the following is excerpted with attribution from a publication by Troutman Pepper. (Find the full text HERE)

The Affordable Care Act requires MA insurers to report and return any overpayments identified by the insurer to CMS within 60 days. Failure to do so can trigger liability under the False Claims Act. In 2014, CMS promulgated the Overpayment Rule to implement these statutory requirements and further specified that a “diagnosis that has been submitted [by a Medicare Advantage insurer] for payment but is found to be invalid because it does not have supporting medical record documentation would result in an overpayment.” Becerra, 2021 WL 3573766, at *10. For purposes of the rule, overpayments are “identified” when actually identified or when they should have been identified by the insurer “through the exercise of reasonable diligence.” “Reasonable diligence” is defined as “proactive compliance activities conducted in good faith by qualified individuals to monitor for the receipt of overpayments.” 42 C.F.R. § 422.326 at 29,921.

Documentation of a reported medical diagnosis is relevant here because of the way CMS pays MA insurers. Unlike traditional fee-for-service (FFS) Medicare payments, MA insurers receive pre-established monthly lump sum payments for each beneficiary they insure. The monthly payment amounts are intended to reflect the relative risk and cost of insuring any particular member. To that end, the Medicare statute requires a monthly payment adjustment to reflect “such risk factors as age, disability status, gender, institutional status, and … health status … , so as to ensure actuarial equivalence” between traditional Medicare and Medicare Advantage. MA insurers are then paid larger amounts for covering higher risk, costlier individuals. 42 U.S.C. § 1395w-23(a)(1)(C)(i).

CMS uses the Hierarchical Condition Category risk adjustment model to convert diagnosis data into expected costs for MA beneficiaries. The model uses data from individuals covered under the traditional Medicare program to determine medical costs associated with certain diagnosis and demographic information. CMS then uses this data to predict the cost of care for MA beneficiaries based on their demographics and diagnoses.

Since errors may occur in reporting diagnosis codes, CMS has implemented mechanisms, including the Overpayment Rule, to validate reported diagnoses. Another validation mechanism is the Risk Adjustment Data Validation audit through which CMS audits a sample of medical records for any unsupported diagnoses that may have resulted in an overpayment. CMS then extrapolates this sample’s error rate across all beneficiaries. At one point, CMS considered adding, but ultimately did not, an FFS adjuster to achieve actuarial equivalence in the RADV program. The FFS adjuster would be applied to any overpayment amounts to ensure that MA insurers were only liable for repayments that exceeded any payment errors under the traditional Medicare program. The FFS adjuster was at issue in the challenge to the Overpayment Rule before the D.C. Circuit.

Implications

With this opinion, the D.C. Circuit disfavored arguments advanced by Medicare Advantage insurers and the District Court, largely reinstating the Overpayment Rule and shoring up CMS’ authority to implement fraud prevention and cost containment measures in a variety of forms. Importantly though, this opinion did not disturb the significant victory Medicare Advantage insurers enjoyed at the District Court concerning the reasonable diligence requirement, which the court ruled could not be applied to lower the standard for False Claims Act Liability. Even so, Medicare Advantage insurers must remain diligent in their compliance procedures. As the Circuit Court made clear, CMS has several tools in its arsenal — including certification obligations, RADV audits, and the Overpayment Rule — to identify and recoup overpayments and to potentially impose substantial liability for erroneous coding submissions. Read the full article here.

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

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

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

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

Passive PEMs are not how to change physician behavior.

… reviews showed that formal didactic conferences and passive forms of CME, such as brochures or printed educational materials (PEMs), are the least effective methods for change and, at best, create small changes within practice. Other forms of passive dissemination, such as mailing PEMs to clinicians, were also deemed ineffective in changing physician behavior when used alone.

However, printed educational materials may be effective for raising awareness about specific behavior change. It is important to recognize that these passive approaches represent the most common approaches adopted by various healthcare organizations. 

So to reiterate, the most common approach is to distribute printed materials, emails, PDFs, flyers, email blasts and the like. And this is shown to be the least effective approach.

The goal of continuing medical education (CME) for many medical professionals is to do more than raise awareness. Rather, the aim of CME is to see ongoing growth in physician performance. What methods then are most effective for creating the desired change? 

Active and multifaceted methods are how to change physician behavior.

Various implementation methods are utilized to try and change physician behavior, and implementing the most effective ones is crucial to success. Our findings provide a comparison of relative effectiveness of various interventions, indicating that active forms of CME and multifaceted interventions are the most effective. In general, active approaches to changing physician performance have been shown to improve practice to a greater extent than traditional passive methods. 

Active approaches … led to greater effects than traditional passive approaches. According to the findings of 3 reviews, 71% of studies included in these reviews showed positive change in physician behavior when exposed to active education methods and multifaceted interventions.

Active education methods and multifaceted interventions are the most effective when it comes to growth in physician behavior. The DoctusTech App is designed to provide active education and multifaceted interventions. In short, our app helps facilitate your desired growth as a physician. In fact, our app excels at providing the most effective methods of intervention. 

…interactive education methods were identified in 3 reviews as highly effective single intervention methods for changing physician practice patterns. Interactive educational methods or active forms of CME are non didactic or lecture-based learning, focus on facilitating physician discussion, and link education experience to the physician’s clinical cases. Reminders (concurrent and automatic) were also recommended due to consistent positive results.

Deep learning is about more than gathering knowledge.

Deep learning is about more than gathering knowledge. The best way to learn is to practice and apply information. Our app allows for interactive and engaged learning by offering challenging questions in a clinical vignette to both teach and reveal gaps in knowledge while offering explanations that deepen understanding.

…learning linked to clinical practice and self-directed multifaceted active educational methods both resulted in improved physician performance.

Our study indicated that practices should focus on implementation of active methods to change physician behavior and limit use of passive dissemination of educational material or formal didactic conferences.

The DocusTech App is also multifaceted in its approach to improving physician performance! Along with engaging questions, our app incentivizes and gamifies the learning process by comparing the results within your organization in order to determine where you organization lands externally with all users. The challenging questions and incentivizing nature of our app is designed to promote deep engagement through ongoing discussion and learning among physicians. 

…multifaceted interventions were most effective in changing physician practice patterns. Multifaceted interventions included a combination of active interventions: audit and feedback, reminders, local consensus or marketing, academic outreach, and interactive education.

The DoctusTech app knows that Active and Multifaceted methods are how to change physician behavior.

The DoctusTech App utilizes the same methods that have proven to help improve physician behavior. And just to reiterate, this is not a zoom call, a classroom style lecture, an email blast, or printed flyers. There are proven to be far less impactful or effective. Our app utilizes the most advanced intervention methods with the aim of replacing boring and ineffective lecture-style learning with engaging, challenging, and on-demand learning through questions that test your knowledge while filling-in knowledge gaps.

…multifaceted interventions and active forms of CME were rated the most effective implementation methods to change physician behavior for a desired outcome.

Are you struggling with how to change physician behavior? 

See how the DoctusTech app is changing physician behavior right now! Using multifaceted and deeply engaging interventions, educating physicians on HCC coding has never been more effective and efficient.

Schedule a conversation with Dr. Kazi today, and start to see change physician knowledge, behavior and accuracy in HCC coding today!.

Book a demo today.

Medicare Advantage Compliance Audits: The Department of Health and Human Services Office of Inspector General regularly audits Medicare Advantage contracts and reports out specific diagnosis codes deemed improper. They also report the estimated overpayments associated with the specific diagnosis codes, and recommend repayments.  Below, you’ll find all of the specific “High Risk HCC codes” targeted in these recent HHS OIC Medicare Advantage compliance audits.

High Risk HCC codes targeted in 6 recent HHS OIG Medicare Advantage compliance audits:

And the organizations associated with misuse

Why OIG Does These Audits

Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services (CMS) makes monthly payments to MA organizations according to a system of risk adjustment that depends on the health status of each enrollee. Accordingly, MA organizations are paid more for providing benefits to enrollees with diagnoses associated with more intensive use of health care resources than to healthier enrollees, who would be expected to require fewer health care resources.

To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS. Some diagnoses are at higher risk for being miscoded, which may result in overpayments from CMS.

In the past few months, a large number of these audits have been released. Here are the summaries of just a few.

HHS OIC Medicare Advantage compliance audit #1

Humana, Inc. – $197.7 Million

How OIG Did This Audit

For this audit, we reviewed one of the contracts that Humana, Inc., has with CMS with respect to the diagnosis codes that Humana submitted to CMS. Our objective was to determine whether Humana submitted diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements.

We selected a sample of 200 enrollees with at least 1 diagnosis code that mapped to an HCC for 2015. Humana provided medical records as support for 1,525 HCCs associated with the 200 enrollees. We used an independent medical review contractor to determine whether the diagnosis codes complied with Federal requirements.

Humana Did Not Submit Some Diagnosis Codes in Accordance With Federal Requirements

1. Some of the Diagnosis Codes That Humana Submitted to CMS
   Were Not Supported in the Medical Records
2. Diagnosis Codes That Humana Should Have Submitted but Did Not
   Submit to CMS

What OIG Found

Humana did not submit some diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements. First, although most of the diagnosis codes that Humana submitted were supported in the medical records and therefore validated 1,322 of the 1,525 sampled enrollees’ HCCs, the remaining 203 HCCs were not validated and resulted in overpayments. These 203 unvalidated HCCs included 20 HCCs for which we identified 22 other, replacement HCCs for more and less severe manifestations of the diseases. Second, there were an additional 15 HCCs for which the medical records supported diagnosis codes that Humana should have submitted to CMS but did not.

Thus, the risk scores for the 200 sampled enrollees should not have been based on the 1,525 HCCs. Rather, the risk scores should have been based on 1,359 HCCs (1,322 validated HCCs + 22 other HCCs + 15 additional HCCs). As a result, we estimated that Humana received at least $197.7 million in net overpayments for 2015. These errors occurred because Humana’s policies and procedures to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective.

What OIG Recommends and Humana’s Comments

We recommend that Humana refund to the Federal Government the $197.7 million of net overpayments and enhance its policies and procedures to prevent, detect, and correct noncompliance with Federal requirements for diagnosis codes that are used to calculate risk-adjusted payments.

Humana disagreed with our findings and with both of our recommendations. Humana provided additional medical record documentation which, Humana said, substantiated specific HCCs. Humana also questioned our audit and statistical sampling methodologies and said that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program. After reviewing Humana’s comments and the additional information that it provided, we revised the number of unvalidated HCCs for this final report. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program. We revised the amount in our first recommendation from $263.1 million (in our draft report) to $197.7 million but made no change to our second recommendation.

Source: oig.hhs.gov/oas/reports/region.pdf

HHS OIC Medicare Advantage compliance audit #2

UPMC Health Plan, Inc. –  $6.4 million

How OIG Did This Audit

For this audit, we reviewed one MA organization, UPMC Health Plan, Inc. (UPMC), and focused on 10 groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that UPMC submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.

We sampled 280 unique enrollee-years with the high-risk diagnosis codes for which UPMC received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $975,223.

Most of the Selected High-Risk Diagnosis Codes That UPMC Submitted to CMS Did Not Comply With Federal Requirements

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

What OIG Found

With respect to the 10 high-risk groups covered by our audit, most of the selected diagnosis codes that UPMC submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 194 of the 280 enrollee-years, the diagnosis codes that UPMC submitted to CMS were not supported in the medical records and resulted in $681,099 of net overpayments for the 194 enrollee-years.

These errors occurred because the policies and procedures that UPMC had to ensure compliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. On the basis of our sample results, we estimated that UPMC received at least $6.4 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.

What OIG Recommends and UPMC Comments

We recommend that UPMC refund to the Federal Government the $6.4 million of estimated net overpayments; identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and continue its examination of existing compliance procedures to identify areas where improvements can be made to ensure that diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS’s risk adjustment program) and take the necessary steps to enhance those procedures.

UPMC disagreed with our findings and recommendations. UPMC provided additional information which, according to UPMC, validated HCCs for 25 sampled enrollee-years. UPMC questioned both our audit methodology and the qualifications of our independent medical review contractor. UPMC also stated that we did not calculate overpayments according to CMS requirements and that it disagreed with our extrapolation methodology and our assessment of its compliance program. After reviewing UPMC’s comments and the additional information that it provided, we revised the number of enrollee-years in error for this final report. We followed a reasonable audit methodology, used a qualified medical review contractor, correctly applied applicable Federal requirements underlying the MA program, and properly assessed UPMC’s compliance program. We revised the amount in our first recommendation from $6.6 million (in our draft report) to $6.4 million but made no change to our other recommendations.

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

HHS OIC Medicare Advantage compliance audit #3

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

How OIG Did This Audit

We sampled 240 unique enrollee-years with the high-risk diagnosis codes for which Healthfirst received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $787,928.

Most of the Selected High-Risk Diagnosis Codes That Healthfirst Submitted to CMS Did Not Comply With Federal Requirements

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

What OIG Found

With respect to the seven high-risk groups covered by our audit, most of the selected diagnosis codes that Healthfirst submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 155 of the 240 enrollee-years, the diagnosis codes that Healthfirst submitted to CMS were not supported in the medical records and resulted in net overpayments of $516,509.

These errors occurred because the policies and procedures that Healthfirst had to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. On the basis of our sample results, we estimated that Healthfirst received at least $5.2 million in net overpayments for these high-risk diagnosis codes in 2015 and 2016.

What OIG Recommends and Healthfirst Comments

We made a series of recommendations to Healthfirst, including that it: refund to the Federal Government the $5.2 million of net overpayments; identify, for the diagnosis codes described in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and continue its examination of existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes that are at high risk for being miscoded comply with Federal requirements and take the necessary steps to enhance those procedures.

Healthfirst objected to all of our recommendations; however, it did not object to any of the errors we identified. Instead, Healthfirst requested we limit our recommended recovery to the overpayments identified in our sample-not the extrapolated value of those overpayments. Healthfirst stated that OIG lacked the authority to use extrapolation to recommend a repayment and disagreed with our extrapolation methodology. It also stated that our audit methodology did not account for a payment principle known as “actuarial equivalence” and disagreed that it should perform audits of high-risk diagnoses or enhance its compliance program. After reviewing Healthfirst’s comments, we maintain that our findings and recommendations are valid. No statutory authority limits our use of extrapolation to estimate a recovery and we correctly applied Federal requirements underlying the MA program.

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

HHS OIC Medicare Advantage compliance audit #4

Tufts Health Plan –  $3.7 million

How OIG Did This Audit

For this audit, we reviewed one MA organization, Tufts Health Plan, Inc. (Tufts), and focused on seven groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Tufts submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.

We sampled 212 unique enrollee-years with the high-risk diagnosis codes for which Tufts received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $746,427.

Most of the Selected High-Risk Diagnosis Codes That Tufts Health Plan Submitted to CMS Did Not Comply With Federal Requirements

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

What OIG Found

Most of the selected diagnosis codes that Tufts submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 58 of the 212 sampled enrollee-years, the medical records validated the reviewed Hierarchical Condition Categories (HCCs). However, for the remaining 154 enrollee-years, the diagnosis codes were not supported in the medical records. These errors occurred because the policies and procedures that Tufts had to ensure compliance with CMS’s program requirements, as mandated by Federal regulations, could be improved. As a result, the HCCs for some of the high-risk diagnosis codes were not validated. On the basis of our sample results, we estimated that Tufts received at least $3.7 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.

What OIG Recommends

We recommend that Tufts: (1) refund to the Federal Government the $3.7 million of net overpayments; (2) identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and (3) continue to improve its existing compliance procedures to identify areas where improvements can be made to ensure diagnosis codes that are at high risk for being miscoded comply with Federal requirements (when submitted to CMS for use in CMS’s risk adjustment program) and take the necessary steps to enhance those procedures.

Tufts did not concur with our findings and recommendations. Tufts stated that we should not have included the errors associated with 5 enrollee-years in our calculation of total net overpayments because, according to Tufts, it had already submitted corrections to CMS. Tufts did not specifically comment on the errors associated with the other 154 enrollee-years. Tufts disagreed with our sampling and review methodologies, and stated that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program.

After consideration of Tufts’ comments, we maintain that our findings and recommendations are valid. However, we revised our findings for the 5 enrollee-years and considered the impact of the budget sequestration reduction; therefore, we reduced our first recommendation from $4,013,034 to $3,758,335 for our final report. We also revised the beginning of our third recommendation in recognition of Tuft’s past efforts to improve its compliance program.

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

HHS OIC Medicare Advantage compliance audit #5

Anthem Community Insurance Company, Inc. – $3.47 million

How OIG Did This Audit

For this audit, we reviewed one MA organization, Anthem Community Insurance Company, Inc. (Anthem), and focused on seven groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Anthem submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.

We sampled 203 unique enrollee-years with the high-risk diagnosis codes for which Anthem received higher payments for 2015 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $599,842.

Most of the Selected High-Risk Diagnosis Codes That Anthem Submitted to CMS Did Not Comply With Federal Requirements

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

What OIG Found

With respect to the seven high-risk groups covered by our audit, most of the selected diagnosis codes that Anthem submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 123 of the 203 enrollee-years, the diagnosis codes that Anthem submitted to CMS were not supported in the medical records and resulted in $354,016 of net overpayments for the 203 enrollee-years.

These errors occurred because the policies and procedures that Anthem had to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. On the basis of our sample results, we estimated that Anthem received at least $3.47 million of net overpayments for these high-risk diagnosis codes in 2015 and 2016.

What OIG Recommends and Anthem Comments

We recommend that Anthem refund to the Federal Government the $3.47 million of net overpayments; identify, for the high-risk diagnoses included in this report, similar instances of noncompliance that occurred before or after our audit period and refund any resulting overpayments to the Federal Government; and enhance its compliance procedures to focus on diagnosis codes that are at high risk for being miscoded by (1) determining whether these diagnosis codes (when submitted to CMS for use in CMS’s risk adjustment program) comply with Federal requirements and (2) educating its providers about the proper use of these diagnosis codes.

Anthem did not concur with our findings and recommendations. Anthem disagreed with our findings for 2 specific enrollee-years and provided additional explanations. Anthem also did not agree with the methodologies that we used to review the selected diagnoses and to calculate the $3.47 million of net overpayments. Anthem also said that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program.

After reviewing Anthem’s comments and the information provided, we maintain that all of our findings and recommendations remain valid. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program.

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

HHS OIC Medicare Advantage compliance audit #6

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

How OIG Did This Audit

For this audit, we reviewed one MA organization, Coventry Health Care of Missouri, Inc. (Coventry), and focused on six groups of high-risk diagnosis codes. Our objective was to determine whether selected diagnosis codes that Coventry submitted to CMS for use in CMS’s risk adjustment program complied with Federal requirements.

We judgmentally selected 275 unique enrollee-years with the high-risk diagnosis codes for which Coventry received higher payments for 2014 through 2016. We limited our review to the portions of the payments that were associated with these high-risk diagnosis codes, which totaled $701,593.

Most of the Selected High-Risk Diagnosis Codes That Coventry Submitted
to CMS Did Not Comply With Federal Requirements

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

What OIG Found

Most of the selected diagnosis codes that Coventry submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 226 of the 275 enrollee-years, the diagnosis codes that Coventry submitted to CMS were not supported in the medical records.

These errors occurred because the policies and procedures that Coventry had to detect and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective. As a result, Coventry received $548,852 of net overpayments for 2014 through 2016.

What OIG Recommends and Coventry’s Comments

We recommend that Coventry refund to the Federal Government the $548,852 of net overpayments; identify, for the diagnoses included in this report, similar instances of noncompliance that occurred during our audit period that we did not review and outside of our audit period and refund any resulting overpayments to the Federal Government; and enhance its compliance procedures to focus on diagnosis codes that are at high risk for being miscoded by: (1) educating its providers about the proper use and documentation of these diagnoses and (2) determining whether these diagnosis codes (when submitted to CMS for use in CMS’s risk adjustment program) comply with Federal requirements.

Coventry agreed that most of the reviewed diagnosis codes were not supported by medical records and said that it had identified $542,541 to refund to the Federal Government. However, Coventry did not agree with the other findings associated with our first recommendation and submitted additional documentation for our consideration. Coventry did not agree with our other recommendations and said that our report contained a number of serious flaws that fundamentally undermined our audit methodology, findings, and recommendations. Coventry also stated that it had made enhancements to its compliance processes since our audit period, including provider education.

After reviewing Coventry’s comments and the additional documentation that it provided, we revised the number of enrollee-years in error. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program. We revised the recommendation to refund overpayments from $584,005 (in our draft report) to $548,852 and slightly revised some of the language in our third recommendation.

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

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Other stories like HHS OIC Medicare Advantage compliance audits

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

The DOJ DOJ Healthcare Audits Charged $5 Billion In 2021, according to a recent report. The Department of Justice released an analysis of all False Claims Act settlements and judgments in fiscal year 2021, revealing $5 Billion against healthcare, out of a $5.6B total. Healthcare represented 89% of all DOJ FCA judgments and settlements for the year.

The False Claims Act is the government’s primary civil tool to redress false claims involving other government operations and functions. 

In the False Claims Act history, this is the second largest annual total, and the largest since 2014. Settlement and judgments now total north of $70 billion since 1986, when Congress substantially strengthened the civil False Claims Act by boosting incentives up to 30% for whistleblowers. In 2021, whistleblowers filed 598 qui tam suits.

DOJ Healthcare Audits account for nearly 90% of all DOJ charges

Of the more than $5.6 billion in settlements and judgments reported by the Department of Justice this past fiscal year, over $5 billion relates to matters that involved the healthcare industry, including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories and physicians. The amounts included in the $5 billion reflect recoveries arising from only federal losses, and, in many of these cases, the department was instrumental in recovering additional amounts for state Medicaid programs.

First Place:  Health Care Fraud

Healthcare fraud was once again in the lead as the top source of the department’s False Claims Act settlements and judgments. The department’s efforts restore funds to federal programs such as Medicare, Medicaid and TRICARE and prevent billions in losses by acting as a deterrent. Often, also protecting patients from medically unnecessary or potentially harmful actions.

Second Place: Medicare Advantage

Prosecuting Plans AND Providers for Over-Coding, Up-Coding

In 2021, more than 26 million Medicare beneficiaries were enrolled in Medicare Advantage plans, and the Congressional Budget Office projected that CMS would pay more than $343 billion for those plans.

The department has pursued plans and healthcare providers that manipulated the risk adjustment process by submitting unsupported diagnosis codes to make their patients appear sicker than they actually were. This year, Sutter Health, a California-based health care services provider, paid $90 million to resolve allegations that it knowingly submitted unsupported diagnosis codes for certain patient encounters, resulting in inflated payments to be made to the Medicare Advantage Plans and Sutter Health. In addition, Kaiser Foundation Health Plan of Washington, formerly known as Group Health Cooperative (GHC), paid $6.3 million to resolve allegations that it submitted invalid diagnoses and received inflated payments as a result. In addition, the department intervened and filed complaints in separate lawsuits against Independent Health Corporation and members of the Kaiser Permanente consortium alleging that those Medicare Advantage organizations submitted or caused the submission of inaccurate information about the health status of beneficiaries enrolled in their plans to increase reimbursement from Medicare.

Other areas of Settlements and Judgments:

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

Source: DOJ

Excerpts from a study.

Humana’s Chief Medical Officer, William Shrank, MD, MSHS, co-wrote a study in March (published by JAMA)  titled “Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries.” (Gondi S, Li Y, Drzayich Antol D, Boudreau E, Shrank WH, Powers BW. Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries. JAMA Netw Open. 2022;5(3):e222916. doi:10.1001/jamanetworkopen.2022.2916)

It is a very quick read, but here’s the highlight reel:

Downside Risk vs. Fee For Service

“Compared with FFS, beneficiaries cared for under 2-sided risk models had lower rates of hospitalizations, observation stays, and ED visits.”

“Compared with FFS, 2-sided risk models were associated with a 15.6% (95% CI, 14.2%-17.0%) relative reduction in avoidable hospitalizations, compared with 4.2% (3.4%-4.9%) for all-cause hospitalizations (Figure).”

Upside Risk vs. Fee For Service

“For all outcomes, there was no significant difference in acute care use between beneficiaries cared for under upside-only risk models and FFS.”

Further Discussion

“In this study of MA beneficiaries, advanced value-based payment arrangements (ie, 2-sided risk models) were associated with lower rates of acute care use, especially those events that are potentially avoidable. These findings are consistent with evaluations of value-based payment in traditional Medicare and serve to expand the evidence base around value-based payment models in Medicare Advantage.1 The lack of significant differences between FFS and upside-only risk models suggests that downside financial risk may play a key role in effective value-based payment arrangements.”

This study had limitations. 

Stephen Kemble, MD (Queen’s Medical Center, Honolulu) and Gordon Moore, MD, MPH (Professor of Population Medicine, Harvard Medical School, Boston, MA) both brought up valid concerns in the comments section, calling out the potential for selection bias, and even asserting that the study does not answer the question it purports to address.

Obviously, there is more to learn. But what do you think? Is the data telling you that downside risk decreases avoidable hospitalizations? Or is something else at play? And if so, what do you think it is?

A guest walks into an upscale hotel and unburdens himself of several suitcases into the waiting hands of an eager bellhop. When both arrive at the room, rather than giving a tip, the guest offers a hearty thanks! With a dry smile, the bellhop frankly states, “‘Thank you’ don’t feed the bulldog.”

And he’s right. For all the talk of improving outcomes and reducing costs, it takes money to provide the kind of care that truly improves outcomes. But in the same breath, caring for the health of a population is very clearly not about the money. So how does a $4+ TRILLION-with-a-T industry improve outcomes and reduce costs while balancing on the razor-thin line that both is and is not about the money?

In the Value-Based Care space, the full risk model is often called the “silver bullet,” AKA the only thing going that is trending toward a sustainable solution.  Full risk is, in fact, all about the money: how it is deployed, where it is directed, and what mechanisms are in place to either gain or lose the money.

(But also, it’s not about the money.)

Provider groups are not jumping ship from their traditional fee-for-service model into full risk because each clinician in the group finds herself in need of a new boat. The transition from FFS to VBC is driven by that same spark that drew optimistic kids out of college and into medical school: the desire to help people.

And nothing helps people stay healthy like a full risk model, or as it’s known in some corners of the world, “Mutual Assured Destruction.”

The HCPLAN’s annual report  (Health Care Payment Learning & Action Network) shows a slow but consistent rise in dollars spent in VBC arrangements, and a glacially slow (but steady!) decline in dollars spent in FFS arrangements.

The proof is in the pudding. And the pudding is made out of data. Humana’s Chief Medical Officer, William Shrank, MD, MSHS, co-wrote a study in March that seeks to answer the correlation between avoidable hospital visits and models of payment and risk. Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries (Gondi S, Li Y, Drzayich Antol D, Boudreau E, Shrank WH, Powers BW. Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiaries. JAMA Netw Open. 2022;5(3):e222916. doi:10.1001/jamanetworkopen.2022.2916).

In that piece, we see the smoking gun that fired the silver bullet that is gradually improving outcomes and reducing costs:

So in a fair fight, when it comes to reducing avoidable hospitalizations, full risk—or 2-sided risk, downside risk—beats both FFS AND shared savings by a healthy margin.

You have probably heard the phrase “the fear of pain is a greater motivator than the desire for pleasure.” Freud, Maslow, and even Psychology Today speak to this, but very few examples illustrate the principle so vividly as when comparing upside risk or “shared savings” (a reward) against 2-sided risk models (full risk, AKA the opportunity to lose money).

This is also known as “aligning incentives.” Simply put, if Jerry stays healthy, Jerry’s doctor keeps more money, but if Jerry takes a costly trip to the ED (Expensive Department), his full-risk-bearing healthcare provider pays the piper.  

While Jerry may be motivated to keep his diabetes under control and stick with his medication, his provider is financially incentivized to do all of the things that reduce those avoidable hospitalizations.

 Beyond the annual wellness visit, there are myriad things that are shown to reduce those acute events. Send Jerry home with a remote patient monitoring device and assign staff to monitor the results. Call Jerry to ensure he’s doing okay. Ensure he has transportation to and from the clinic. Offer other services in clinic to make Jerry want to come for a visit. (Looking at you, Florida, with the haircuts, mani-pedis, fresh produce, mental health counseling, and full-time massage therapist, all at no cost to Jerry.)

Obviously, in the relationship between money and healthcare, it’s complicated…. But by shifting risk in the direction of providers, the data show that avoidable hospitalizations are less and outcomes are improving, which directly impacts cost of care. 

Healthier patients, happier doctors, silver bullet.

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

“There are a lot of other programs out there, but not like this.” – Dr. Jose a Villaplana-Canals, MD

“Providers are not going to be able to do this much longer without tools. Even the Cadillac of EMRs has its limitations, and you’re never going to get away from provider education; it’s necessary.” – Teresa Caniglia, CDI

1. The format is easy and convenient to use

HHC coding education right on your phone makes it easy to learn, anytime, any place. Unlike lectures or even one-on-one coaching, the simplicity and convenience of the app allow you to engage in ongoing training throughout the day. Although, it only takes about 5 minutes per week to stay up to date!

It’s an easy format to follow. The mobile app is really easy to use and launch. It’s nice just having it with you rather than trying to read an article or listen to a podcast. . – Dr. Joseph Bateman

The mobile app is wonderful in that it’s a clinical vignette – it’s what is literally in front of their face, and it gets them thinking. – Teresa Caniglia, CDI

It’s nice. You know, I’ll be sitting down to eat something, or I’ll be sitting in a waiting room somewhere waiting to go to my doctor, physical therapy, whatever. Then I’ll just pull the app up, and I’ll do, you know, five or ten questions, click and shut it down, and you go do your thing. – Dr. Joseph Bateman

The app seems easy to use. – Dr. Jeffrey Linder

2. Clinical Vignettes increase memory and insights

Deep learning isn’t just about getting the information, it is about knowing what to do with that information. The DoctusTech App helps you learn through challenging questions that reveal gaps in knowledge and explanations that deepen understanding.

I like the concise feedback you get when you get a question wrong. And it tracks your progress. Looking at the right answer and why it’s the right answer – that’s very, very helpful. – Dr. Joseph Bateman

And yes, you miss questions, but that’s how you learn. And you can read afterward the rationale for the answers, and you learn right there. – Dr. Jose a Villaplana-Canals, MD

Our app also incentivizes ongoing learning by gamifying the process of growing in your knowledge of HCC coding. You can compare results within your organization and determine where your organization lands externally with all users.

I like to be challenged, and that’s the way I learn – because it makes you remember. – Dr. Jose a Villaplana-Canals, MD

It’s concise, challenging, and when you find yourself between 2 answers, it’s challenging and makes you think! – Dr. Jose a Villaplana-Canals, MD

The app also helps with knowledge retention in ways that are impossible with lectures and books alone.

And I also liked the fact that the information key principles are continuously repeated and asked in a different way. So you really get to know the concept. And it becomes more intuitive for you when you’re working on a patient’s chart. – Dr. Joseph Bateman

When you’re seeing patients, you remember the questions, and you remember what you need to ask the patients. – Dr. Jose a Villaplana-Canals, MD

This highlights your knowledge and what you do or don’t know. The detailed answers help me to understand why it’s the right answer – Dr. Cynthia Ambler

3. The information is current and up-to-date

You need current, relevant and up-to-date information. The best way to stay up to date on all the changes in HHC coding is by regularly engaging with the Doctus Tech App.

You’re never going to be able to teach them everything they need to know in 60-90 minutes. This is never going to be a one-and-done. Medicine is broad, and it’s changing and developing. – Teresa Caniglia, CDI

It is definitely up to date. Any educational program helps physicians prep for boards, so this is a board question format. And that helps. – Dr. Jose a Villaplana-Canals, MD

As the body of knowledge grows, surely the use of digital tools is going to become pretty normal. – Dr. Joseph Bateman

I learned so many interesting things that I didn’t know I should look for. – Dr. Vljayalakshml Thota

4. The format is designed for learning

The DoctusTech App is designed to help you navigate the complex and changing world of HHC coding. The aim of our app is to replace boring lecture-style learning with engaging, challenging, and on-demand learning through questions that test your knowledge while filling-in knowledge gaps.

Question prompts are long, but I learned a lot. – Dr. Laura Tagle

It’s changing the way I’m thinking and how I’m going to document. I wasn’t consistent before this training. It’s an essential self-improvement exercise. – Dr. Patrick Towne

Content looks like my patient population. I’m trying to apply what I learned to my documentation now because it directly relates to my patient care. – Dr. Steven Lobue

Those of us in the know and leadership understand the importance of this and how it’s going to play an increasing role in our ability to deliver, to get paid, to deliver complex care. I personally understand how important it is to have someone use this versus another form of learning. I feel is that this is more intuitive and is full of kind of “aha” moments. All of my other education on this topic hasn’t really been that iterative or intuitive. I think this is the best thing I’ve come across to teach us some of the basic tenants. I got more out of it than I anticipated. I think you underpromised and over-delivered.  – Dr. Joseph Bateman

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 DOJ vs Sutter Health? 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Does the patient really actually have that diagnosis?

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

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

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

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

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

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

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

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

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

Sutter Health Settles with the DOJ is not a phrase we thought we’d ever see on our blog. We recently published a white paper on RADV audits and the importance of strict HCC compliance. A few weeks later, the Department of Justice announced a groundbreaking $90 million settlement with provider group Sutter Health. 

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

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

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

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

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 HCC Coding is Good For the Country Episode 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 HCC Coding is Good For Providers episode 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.

HCC Coding is Good For Providers Financially

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

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

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

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

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

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

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

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

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

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

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

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

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

HCC Coding is Good For Providers When They Work With Us

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

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

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

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

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

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

Battling Physician Burnout is a top priority. One pillar of The Quadruple Aim is to Improve the clinician experience. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

Live with Dr. Kazi – HCC Coding is Good For Patients

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.

RADV Audit White Paper – Planning Ahead For Strict HCC Compliance Protocols

Key Findings on  From 400 RADV Audits, 2011-2021 

What is a RADV Audit?

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

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

How does a RADV Audit work?

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

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

Takeaway 1: Small errors return large chargebacks

Extrapolating from statistics based on errors yields significant sums.

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

Takeaway 2: Some codes get misused more than others

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

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