Holly Cassano: Good afternoon.
My name is Holly Cassano, and I am a CPC, CRC and your host; as well as Kim Dues who
is also a CPC, CRC.
We are with BillingParadise and we are here to present to you a free webinar on Risk Adjustment
Fraud and Not Just Another ìFî Word.
Hope everyone is doing well today.
Kim Dues: Good afternoon.
We are happy to be here.
Holly Cassano: Yes we are.
Hope everyone is having a great Wednesday.
We have almost made it to Friday, at this point.
Kim Dues: Yes, yes.
Holly Cassano: Yeah, okay.
So Kim I am going to just kind of proceed forward, you know some of the things we are
going to talk about today, you know to help everyone out is, you know that risk adjustment
is a very confusing topic for many people.
You know, health plans have trouble with it, you know providers have trouble with it as
well as coders like ourselves and auditors.
So, what we are trying to get today is kind of give you a little bit of some basics in
risk adjustment HCCs overall and then give you some hindsight into RADV Audits and how
both the health plan providers and coders, you know can help work together so that they
ensure that they properly are capturing those HCC codes and kind of moving along together
Some of you may know me, some of you may not.
Just to give you a little background.
I have been in healthcare for a little over 20 years.
Kim will give you a little bit background on herself, but one other things that I have
specialized in is risk adjustment.
And back in 2014, I was approached by the AAPC to help them develop the National Risk
Adjustment CRC credential and also to help develop the National Exams.
So we did beta testing and all of that.
And then in the early 2015, the CRC was finally launched by the AAPC.
So I was one of the eight people on that National Committee.
Kim has an extensive background and is also a CRC as I said and has helped me on many,
many different projects including risk adjustment auditing and so forth.
Kim, do you want to give a little bit of background about yourselves?
Kim Dues: Sure, I took the CRC exam and let me tell you it was tough.
Itís very difficult.
So, it was a really good exam.
So, yeah so I have been in healthcare for about 24 years, started out as an insurance
And I literally went door to door selling insurance, got into securities.
I have a securities license and found my way into healthcare, being that my first time
being and I am grateful to that man for sure.
So, I have built and coded many, many specialties, audited.
I have worked with Holly on several projects and then here we are with BillingParadise.
And we are talking to you today about Risk Adjustment Fraud, Not Just Another ìFî
Over to you, Holly.
Holly Cassano: Thatís right.
Thank you, Kim.
Yeah, you know those of you who know me on, you know, letís kind of put as much of a
positive spin on things as possible especially when we are dealing with things like this
because they do get so intense, you know.
And there is a lot of fraud that happens sometimes, you know itís abuses more you know not really
understanding things, and then there is intent to the fraud.
You know, I always like to try to err on the side if you know possibly that, you know people
really didnít understand what the rules were, you know I like to not assume that their
intent was to defraud, you know, weíre never sure.
And so itís best to kind of assume that it was just a misunderstanding, you know until
Sometimes people tend to forget that in the scheme of things especially with all the different
media stuff that we hear, you know about the different health plans, you know which is
I think that sometimes, you know just before we get into it, you know just to give you
a little insight.
You know I have talked to a lot of different people in the industry, at health plans ñ worked
with health plans.
I worked for a Medicare Advantage Plan myself for several years as well as Cleveland Clinic.
And, you know even Cleveland Clinic had trouble, struggling as well, did the health plan that
I worked for in trying to, you know bridge that gap between capturing these HCC codes
properly, getting documentations all line up, you know with the family providers and
in submitting things into wraps and now we have EBS [Phonetic] [0:04:34] also in the
So one of the things I would like to say is that, you know we know that Medicare performs
risk adjustment validation audits a lot of you have provided medical record documentation,
which helps validate, you know submit the diagnosis codes, as they correlate to HCC
Some of the health findings we have seen recently in headlines of United Healthcare, Freedom
Health, which is you know, in Florida where I am, Humana, Aetna, Optimum Healthcare and
then they have all, you know unfortunately fallen under the scope of the DOJ for allegedly
submitting risk adjustments scores that improperly inflated Medicare advantage reimbursement,
and that was from HealthLeaders Media that they recently reported on that.
I am not saying either way, Iím just reporting what, you know the headlines that I have seen.
You know and things that I know.
You know there are a lot of struggles that are going within health plan trying to get
And for those of you that are participating, that work for a health plan here today or
that participate from a providerís office, you really need to work together, you know
as a team to kind of, you know help each other to capture the data, because at the end of
the day, itís really about your patients and about their health.
And you need to make sure that youíre reporting these chronic conditions accurately to your
health plans so that they can report them accurately to Medicare and get proper reimbursement
not just for themselves or for you guys in provider practices, but overall so that they
can provide better benefits to those members.
And one of those ñ one day soon we are all going to be one of those members of a health
So we want to make sure that we are taking it right now, right Kim?
Well, taking away now to make sure that, you know we can really understand how risk adjustments
works because at the end of the day with value-based care and everything thatís changing in healthcare
today in the landscape its really going to end up more or less into some type of risk
adjustment model where we have to capture these chronic conditions thatís what Medicare
and PQRS attempted it.
Kim Dues: Absolutely.
Female Speaker: Absolutely.
Holly Cassano: You know thankfully, thatís some setting, but now we have MIPS, you know
that we have to deal with, but you know
Kim Dues: Itís got to be a team effort inside that office.
It canít be ñ the team has to create a provider query process.
There are plenty of ìprovider queryî forms out there for you to alter to fit your office
and what a provider query process is about is not telling a provider how to diagnose.
Holly Cassano: Correct.
Kim Dues: Itís trying to get the provider to dig further into the patientís health
and give a specified diagnostic code, so that it meets a medical necessity.
And then, if the patient has conditions that will link ñ to link those conditions so
that, you know they are going to feed into HCC.
Holly Cassano: Right, so just to kind of cover, you know some basics again for those you who
might be new to this industry with Medicare Advantage Risk Adjustment and HCCs, you know,
trying to give more background on that.
For those of you who may not know, you probably may hear several phrases, one of them being
Risk Adjustments Factor score or RAF, when properly recorded.
And what that does, it allows CMS to provide additional reimbursements to Medicare Advantage
Plans, based as I was saying on membersí overall health.
The RAF scores, are derived from the submitted diagnoses from what should be in the medical
And a higher weighted RAF ñ RAF excuse me, correlates to sicker patients, which means
a higher cost in the Medicare Advantage Plan to treat these sicker patients, hence that
means it requires higher reimbursement back to the MA plans in CMS.
The main avenue in which Risk Adjustment Fraud and Abuse occurs, is by recording chronic
conditions and subsequent treatment, on patients that either did not have the reported conditions
or care, or upcoding on existing conditions, to make it seem more severe in nature than
And what I mean by that is letís say if a patient has diabetes and then maybe they
have, you know some neuropathy or something like that or ñ and ñ or itís not really
related but someone might, you know decide to casually relate it when they report it,
not necessarily itís documented that way obviously but they might, you know happen
to do that.
I am not saying they are doing it with intent, but it does happen you know just an error.
But those are things that we want to watch out for.
A little overview about CMSís Hierarchical Condition Categories or HCCs.
You know, Medicare actually introduced them back in 2004 and the goal was to pay the Medicare
Advantage and prescription drug plans accurately and fairly by adjusting payments from rolling
based on their demographics and their healthstatus.
The Risk Adjustment Payment model basically measures the disease burden that include 70
HCCs, which are correlated to diagnosis codes, an accurate diagnosis code documentation of
the ICD-10s and formerly ICD-9s and recording now determines reimbursement needs.
You know, roughly about 8,700 ICD-10 codes that mapped to one of 70 HCCs, and mostly
chronic, but some are acute and previously in ICD-9 we had about 3600, right Kim?
You want to go with that perhaps?
Kim Dues: Yes.
Will you do the next one?
Holly Cassano: Uh-mmm.
Kim Dues: So we got right, if you want to talk about the process?
Holly Cassano: Yeah, letís talk about the process a little bit and then I am going to
hand it over to you for a couple of files.
[Coughs] Excuse me.
Kim Dues: Okay.
Holly Cassano: Yeah, thank you.
Kim Dues: Okay so the process the member face-to-face.
Care and Diagnosis are documented in the page progress notes, ICD-10 codes are submitted
on claims based on face-to-face encounter with clinical findings, claims data, diagnosis
codes are converted to HCC codes.
HCC data submitted to CMS, CMS calculates the Medicare Advantage Risk Adjustment Plan
and providers can deliver ñ and so at the end of the plan and the providers can deliver
better care and reimbursement is received.
Holly Cassano: Thatís correct.
Kim Dues: Um-hmm.
Holly Cassano: The next slide that I added is the payment run dates, and just to kind
of briefly go over that, you know, Kim this.
Kim Dues: Thatís okay, go ahead.
Holly Cassano: I just want to try and mention it briefly because it changed this year or
well actually, last year in April 2016, those of you who know, already have seen this but
for those who have not CMS issued a memo on April 20, 2016 and they changed around the
deadline for submitting risk adjustment data for using the risk code calculations payment
runs for 2016, 2017, 2018.
And what the overall message in that was that they finally decided that they were going
to be planning risk for us.
For 2016 they used 10% of the risk for calculating the diagnosis from accounted data and fee
Some with ñ 90% [Phonetic] [0:11:41] of the risk were calculated with diagnosis from
RAFs and fee for service.
Then, as of this year there is a 25% risk for calculated diagnoses from accounted data
fee for service.
Some of the 75% of the risk were calculated diagnosis from RAFs and fee for service and
then itís going to continue on and increase in that percentage as we progress through
in the coming year.
So, just to what people know, if anyone wants that information just contact me afterwards
or Kim and we are happy to send it to you.
Kim Dues: Sure.
Holly Cassano: Kim, do you want to take payment methodology?
Kim Dues: Absolutely.
Payment Methodology: Payments are based upon acuity of diagnosis, sicker payments ñ patient
will require more active resources.
The diagnoses must be reestablished each year to ensure that next yearís payments will
cover the cost.
For example an amputation must be reported at least once per year to ensure that services
related to this condition will be covered.
So every year they have to say in the environments that this person is an amputate, and the details
of the amputate.
Documentation is must for the diagnosis that are reported and plan for each diagnosis.
So the plan of care has to be spelled out for each diagnosis.
Often times physicians get familiar with patients overtime and neglect documentation on stable
Holly Cassano: Yeah.
Just to speak to that a little bit further, you know often times, you know when I ñ especially
when I worked for the Medicare Advantage Plan for several years I had about, I had three
counties, so I had about 150 providers that were mine those to visit.
And so I would go through tons of medical records and, you know look for different things,
trying to see, you know if there is any puzzle or linking statements between conditions especially
with diabetes and CKB and CHF, etc.
But, one of the biggest things that I used to see that would be forgotten in documentation
annually especially in the first quarter, you know when those patients may need a firm
Annual wellness visit, if theyíre a new patient or if itís their subsequent annual
wellness visit is, you know I could see some from the prior year we have statistics to
look at but, you know say, Mr. Jones, you know he had a below-knee amputation in left
And then, you know in the year before, I mean we were reporting that accurately, but then
in the following year somehow magically, you know we just missed, you know knee came back.
And so we were always wondered how did that happen, you know thatís one of my favorite
But it happens all the time and itís not intentional, itís just a, you know the doctors
are very overwhelmed, you know they got a lot of patient that they have to see.
You know, now they have MIPS, you know for their PQRS, theyíve made full use.
They have all these different things they are trying to capture just for straight Medicare
and then also now we have the Medicare Advantage plans coming along.
Weíre saying okay, oh we need your HEDIS measures, which weíre not going to give
it you today, thereíll be another one.
But you know, but we need you to help us capture these chronic conditions and, you know one
of them that I always see, you know left off the board was the amputations.
You have things like that, or any kind of status condition.
So itís really important to make sure that you capture your status conditions.
They say annually, Medicare says annually, I always recommend at least twice a year to
cover your bases and I recommend at least once in the first quarter, you know to check
the chronic conditions of all your patients and then again in like the third or fourth.
You know Medicare has all the different payment runs throughout the year.
So you want to make sure that you capture them within those payments runs.
So, thatís my recommendation and advice.
Kim Dues: Well, you know let me add to that.
The other things is inside that EMR.
You have to make sure that you as you go forward seeing this patient you need to make sure
that youíll designate active and conditions that are closed out.
So, Holly and I see that all the time when we
We saw that, you know they have a list of 35 diagnoses and 35 different problems and
they all are active.
Well, that canít be.
You have to bring it down and make sure that ones that are active are active and the ones
that are resolved are resolved.
Holly Cassano: Correct.
Kim Dues: Yeah and we all know that you canít code from problem list, you can confirm from
a problem list, but they have to make sure they address it in your assessment plan or
you know somewhere in those notes confirming those conditions and ñ
Holly Cassano: Right.
Kim Dues: Yeah.
Out on Facebook the other day there somebody was talking about coding from lab results.
Do you want to speak to that?
Holly Cassano: Yeah, yeah.
Thatís a big no, no.
Kim Dues: I know, it is a good one.
Holly Cassano: Yeah itís, you know itís unfortunate you know.
But sometimes, you know people get different information, I mean, just like youíre receiving
information from us today.
You know, so itís ñ sometimes itís data overload.
You know maybe there are too many courses out there.
I donít know, but just to make sure that you know if you are a coding professional
or provider of health plan etc., that you just validate your information.
We will have, you know this PowerPoint available so ñ post webinar and, you know I always
put links too, you know where my source of documentation comes from.
So, itís easy to check, but you know itís very important to make sure that, you know
you are following the guidelines.
Medicare published a book basically itís a risk adjustment bible back in 2008, And
you know there is still a lot of people that arenít aware if that exists.
They have updated it to some extent, you know periodically over the course of time, but
they really need to do a full overall.
I think they are just waiting on some different things, you know in government to do so.
But, at some point they will probably redo the entire book.
Kim Dues: Yeah correct.
Holly Cassano: But that is, you know that is ñ that really is, you know the bible
and you can go through the updates that have come out subsequent to 2008 to check things.
But if you have any questions thatís your best bet and also going to the Medicare website
for Risk Adjustment, which we will give you post webinar.
Next we want to talk about a little bit about HCC Payment Methodology and ICD Coding a little
bit further, you know documentation.
Physicians really need to ensure that they are really paying attention to their documentation
and make sure that contains the necessary details, the staff members can choose the
right codes for each patient with that provider.
Besides the increased specificity of a diagnostic code, the doctors also face other documentation
challenges including identification of conditions that contribute to the complexity of a disease,
severity of contributing morbidity, co-morbidity, current stage of the disease such as chronic
kidney disease, dementia and asthma, type of diabetes and itís very ñ and a prehistory
of any present illness and follow up visits.
You know, that physicians at the end of the day are the ones responsible for choosing
the correct diagnosis codes, so I want to make sure I am clear on that.
We want to say that staff members can choose things because staff members when they are
taking, you know the intake information and so forth or if you have a scribe that works
for you, you want to make sure that they are selecting the proper conditions, but you at
the end of the day as a provider have to double check that information to make sure that it
is captured correctly, okay?
Kim Dues: Alright.
Holly Cassano: Alright, letís continue.
Kim, you want to take coding changes?
Kim Dues: I am sorry?
Holly Cassano: Do you want to take coding changes, with ICD-10 and diabetes?
Kim Dues: Sure, sure.
Holly Cassano: Very good.
Kim Dues: Current changes for ICD-10, diabetes communication must
include the type of diabetes.
How about that?
We would love to see whether it is I or II, right?
We have to see.
Body system affected, the complication and manifestation.
If a patient with type II diabetes is using insulin, a secondary code for long-term insulin
Neoplasmís documentation must include first of all the type, malignant, is it primary,
secondary, is it cancer in situ, benign, uncertain, unspecified behavior, the location, I mean
the site of the malignant neoplasm.
If malignant any secondary site should be determined, laterality on papers.
Asthma documentation must include the severity of the disease, mild ñ intermittent, mild
ñ persistent, moderate ñ persistent.
So these are drilling down into these conditions.
I-10 was lotís of advance specific codes, thatís over.
We have to move on and drill down into these codes.
Holly Cassano: Absolutely, I mean just, you know, if youíre going over those, you know
what I am saying it came to mind for me is that, you know now with ICD-10 there is over
200 ICD-10 codes just for diabetes alone.
So, the specificity is really a primary concern for any provider including professional and
The other things you want to keep in mind too, you know in the event of a RADV audit,
you know, you know if you are not being specific and drilling down as Kim said, into your notes
youíre going to get dinged in a RADV audit.
So, we are going to get into that very shortly, but again we just want to give you some of
the basic overviews of whatís going on.
One thing that I would like to mention is the HCC coding impact to revenue.
And what basically I am saying about that is that, you know letís say you had a 76-year-old
female or whatever one male and, you know for a 76-year-old female, you know they captured
a low level of specificity so at the end of the day she actually had diabetes, she had
vascular disease, she had CHF, annular disease interactions.
But at the end of the day they didnít capture any of that.
The total RAF score for that is 0.588 or ñ as of the stats.
And then some conditions coded moderate level specificity with same 76-year-old female would
be ñ and she is Medicaid eligible.
Diabetes with vascular complications, vascular disease without complications, but they missed
CHF and they missed the disease interactions.
So then you get a RAF score for 1.005, and then if you have someone ñ same 76-year-old
female with a high level of specificity where she also is Medicaid eligible they did capture
again the diabetes with vascular complications, vascular disease with complications, arteriosclerosis,
with ulcers et cetera, CHF and you have captured disease interaction then the total RAF score
there is 2.919.
And what that means is when you have no conditions coded, as in the first example that revenue
payback to the health plan is $528, but when you have all of the conditions coded properly
and captured you get revenue back to the health plan from Medicare of $2624.
Thatís a significant difference.
And again itís not just about the money thatís not weíre trying to drive home
We are trying to drive home here that when you accurately capture these chronic conditions
not only does it increases the RAF score appropriately and compliantly, but it also tells Medicare
this patient is really sick and that the plan needs the money in order to pay for the care
of this patient and thatís how you capture those compliantly and correctly.
But itís all about documentation.
So that something that, you know requires you really need to look at along with your
coders and auditors and health plans.
You know, the health plans needs to double check to make sure that what the providers
are submitting, whether they are capitated or partially ñ partial risk or future service,
you know however if itís commercial plan that these diagnoses are being captured correctly,
and that the documentation support that is being submitted at the end of the day.
There are a couple of questions to consider regarding physician documentation and basically
what you can say about the medical record is that, it really is the clinical life story
of that patient.
So one must ask themselves does the documentation paint a complete picture of that patientís
condition and if you canít answer that with a firm yes, then you need to go back to the
beginning and take a look at what has been captured in that patientís clinical life
Would we say so Kim?
Kim Dues: Absolutely I do, for sure.
Holly Cassano: Okay, documentation you know, again you want to properly reflect the memberís
health status, you know for the plans you want to fully assess all chronic conditions
at least annually.
And again, like I said I recommend at least twice thoroughly document in the chart
[0:25:03:29] notes, all conditions evaluated with each visit and code to the highest level
of specificity, just a reminder.
We have some top ten issues with documentation and I call them the top ten fails in documentation.
Number one is failing to capture HCCs at least once every 12 months which, you know, I
[0:25:25] holding us, as youíll hear throughout this entire presentation.
I would say, you know bulletproof your documentation is one of my favorite sayings.
Failure to ensure the medical records obtains a legitimate signature with credential, for
example, to determine whether such as the electronic health record was unauthenticated
not electronically signed.
They need to ensure the diagnosis thatís being billed and the actual medical record
Failure to document according to the need principles, which weíll get into.
Diagnosis needs to be monitored, evaluated, assessed, addressed and treated.
Failure to annually document status decodes in chronic conditions.
Failing, to use a linking statement or document a causal relationship from
Failing to add any diagnosed HCCs or RxHCCs prescription drug HCCs thatís what those
are, to both the chronic problem list in the acute assessment.
Failing to evaluate each of the HCCs, RxHCCs on a semi-annual basis or updates; failing
to review all specialist documentation related to cardiology and master discharge summaries,
radiology specialties correspondence pulmonary.
Epicardial graphs, x-rays, lab results and previous encounters and finally failing to
submit more than the standard four ICD-10 codes.
You want to make sure that, you know Medicare now accepts 12, you want to make sure that
your clearinghouse can facilitate that from a provider standpoint, and most of the plans
are assumed and I hate to use that word, but you know, in line with that now and are looking
for more than those four standard ICD-10 codes.
So if you are not submitting more than four when they are present, you know, chronic conditions
then you need to look into not with your clearinghouse and make sure that they can accept that, because
your social clearinghouse is out there that ñ and EHRs that do not allow the provider
to transmit, you know more than the standard four.
Right actually, that was one of the big pushes with auto clearinghouse to get that done or
same as guidance, so they should definitely be able to put up to 12.
Holly Cassano: At minimum, yes.
Kim Dues: Itís 12.
They should be able to put up to 12.
That was the guidance that was given to the clearinghouses.
So if you have a process in your billing department where your coders code and then the information
goes to data entry, data entry needs to understand, they need to put in every single diagnosis
code, not just four.
So make sure data entry is understanding that that is what they are required to do.
Holly Cassano: Correct.
Kim Dues: Absolutely, because thatís another thing we have seen as we have been in travels
in an outsider, EMR systems and doctorís offices.
Holly Cassano: And all the information I am sharing with you are just the basics, is all
part and parcel of making sure that that medical record is bulletproof in the event of an RADV
One of the other things that we will touch on is the annual wellness visit.
Itís very difficult for Medicare Advantage Plans to get providers to comply with that
annual wellness visit because it is not mandatory.
However, what it mandatory on an annual basis is the HRA.
So, what needs to happen is to have a partner relationship between the Medicare Advantage
Plans and the provider practices and help the practices, you know get in line with getting
Medicare patients in to do their annual wellness visit and their health related assessment.
So, you know, that is something that needs to be worked on, but there are a lot of different
components to the annual wellness visit, but once your practice gets in the line with doing
them and designating, maybe one or two mid-levels in your practice to perform those, thatís
really the best way to utilize, you know your mid-levels with the annual wellness visits
for that particular function.
So, I would recommend looking into that if you are not currently providing annual wellness
visits and HRAs in your practice, you really need to look into that.
Especially, if you are participating with Medicare Advantage Plans because one other
things that can happen, you know, especially if you are not performing well on your HEDIS
measures, if your RAF scores are low because you are just failing to capture these chronic
There is a thing within the plans, then I know because I work for one called ìright
sizing your network.î
And I say it in quotes because itís something that is not very pleasant to say, but Kim
as meanwhile and most of the people that know me, you know, thatís something that I talk
And what I mean by that, is that, when you have a provider that is poorly performing
in your network and you are the Medicare Advantage Plan, you try to do go out, you try to assess
what the problem is, you try to offer assistance to that provider practice to see what the
issues are with them capturing the chronic conditions.
Maybe, it is an issue with documentation, maybe it is an issue with staff, maybe it
is an issue with coverage, maybe it is an issue with just on understanding what needs
to take place for Medicare Advantage Plans and have, and they donít really understand
what HCC codes are.
Because it is slightly different than the documentation that it captures and ready to
use for service, but my standard is this.
If you understand how to document for Medicare Advantage, pretty much you are going to cover
yourself in any type of situation because it is so much more involved and if you understand
PQRS and MIPS documentation and then you pretty much going to be overlooked for your documentation
and you wonít ever have to worry about being right size to every network.
Kim Dues: Alright.
And with that said ñ and with that said, each practice should have a meeting minimum
twice a month with all the providers, with the medical director and they should go over
their documentation as they look out what the coders are giving back to them.
Holly Cassano: Correct.
Kim Dues: So, this query process is a big circle.
And so, that should have meetings with the billing department, go over the queries, the
doctors needs to look at their documentation, review, have the conversations and figure
out where the holes are because it is going to be about the mid-levels choosing the highest
specified code for the patientsí condition and then that documentation needs to match.
And furthermore what we really care, you know I think Holly and I are probably going to
do something separate on the annual wellness visit.
What do you think about that Holly?
Because itís such a big topic and how to use the guidance for Medicare properly and
not only the coding, to follow their guidance from a 10 code, that meet medical necessity.
So anyway, it really is about the whole company, the whole practice tightening up their process.
Holly Cassano: Correct.
Alright, so letís move on.
You know, I think weíve hammered a lot of that tone, for most people, you know and again
if there are any questions about any of this material post, you know webinar just feel
free to contact us and we will be happy to respond.
Letís kind of get into the second half of this as we head down towards the finish line.
You know the CMS-RADV audits, you know I like to say, a lot of people are like, what?
Whatís a RADV audit?
They have heard of audits, they have heard of Medicare audits, but when it comes to RADV
unless they really understand what risk adjustment is and HCC codes they really have never heard
So, you know that RADV stands for Risk Adjustment Data Validation audits.
It is a method of evaluating and validating the accuracy of the diagnosis and a different
payment part of plan.
Itís a proactive action to help reduce the Part C error.
And each year CMS reports the actual payment error estimates, that comply with the Improper
Payments Elimination and Recovery Act which is called IPERA, and that started in 2010.
We have a link to that if you ever want to check it out, just let us know.
And CMS expects that RADV will have a pretty much sentinel effect on the quality of risk
adjustment data submitted for payment going forward into the healthcare continuing with
value based care payments and overall management of chronic care.
And here ñ hence, you know the outcome of MIPS and MACRA.
Kim, do you have anything youíd like to add to that?
Kim Dues: No, I think thatís.
I think thatís spot on, I think itís perfect the way that you went through that.
Holly Cassano: Yeah.
A little bit more about RADV audits for those of you that donít fully know.
CMS audit ensures the integrity and accuracy of the risk adjusted payment.
It verifies as I said the diagnosis that is submitted by the Medicare Advantage Plan and
that itís supported by the medical record documentation for that specific member.
Medicare plans can be selected for RADV audits annually and the selected Medicare Advantage
Plans are required to submit member medicalrecords to evaluate the diagnosis data previously
Provider should also be aware of RADV audits because providers are required to assist the
MA plan by providing medical record documentation for members considered in the audits.
A lot of providers donít really know that or they are not aware of that and they think,
you know, but sometimes, you know, that will just ñ you know, if you work for Medicare
Advantage Plan, this is kind of some of the adjectives that I would get and I donít
mean that negatively, but itís a misunderstanding on the provider part.
That weíre just out there really trying to come into your office or we asked for medical
records itís just really all money to the plan.
But again, I want to stress that on behalf of the plans and having worked on both sides
of the fence.
That is not just about money back to the client.
It is about making sure that the system is operating compliantly and correctly and effectively
in keeping costs down by accurately reporting all these chronic conditions and making sure
that the medical record properly supports those conditions that are reported because
Medicare does audit as we know.
So ñ and if it is not documented what do we say.
Itís not done.
Kim Dues: Not done.
Holly Cassano: You may have mentally done it, or talked about it or something, but if
as a provider you donít actually document it and there is no way to prove that this
was, you know done and performed that it really exist or that you did tests and hereís the
result, the patient has COPD etc.
So, itís a check and balance system.
So anyway, Kim you have anything you would like to add to that?
Kim Dues: No, I think that is very accurate again.
Holly Cassano: Okay.
CMS part of revenue process, as CMS request records that are based on enrolment data for
January as payment year and that plus eligible enrollees partly
during the data collection year, full risk continuously enrolled in the same.
Contract from January of the data collection year through January of the payment year.
Non-ESRD in status from the January of the data collection year through the January of
the payment year.
Non-hospice only starts from January of the data collection year through the January of
the payment year and at least one CMS-HCC assigned, all CMS-HCCs for selected enrollees
will be overviewed.
So thatís the standard process.
Then they do the medical record review, and the record submitted for the RADV, first undergo
an intake evaluation.
For outpatient physician records, the CMS generated attestation maybe similar with the
record thatís missing with provider signature and work credential and only valid records
go forward for coding.
Kim Dues: Thatís right.
Holly Cassano: Medicare advantage organizations managed risk adjustment diagnosis must be
based on clinical medical record documentation, get on face-to-face encounter, patient and
provider, coded in accordance with ICD-10 Standard Guidelines for Coding and Reporting.
Assigned based on need to service within the data collection period and submitted to the
Medicare Advantage contract for acceptable risk adjustment provider type, risk adjustment
provider data source.
Anything you want to say about that Kim?
Kim Dues: No, I will take the next one.
Top 10 RADV Red Flags, members with seven or more HCCs.
Holly Cassano: I love that.
Kim Dues: Members with plus 1 in RAF score from prior year, top 1/3rd paying stratum
diagnosis HCC, RxHCC, high distribution HCCs, active versus history of vascular disease,
diabetes with complications, major depression, protein calorie malnutrition, more than one
status code per member.
Holly Cassano: Yeah.
I would like to speak to that a little bit and thank you for sharing that.
Yeah, often times you know Medicare Advantage Plans as well as Medicare they extrapolate
data, you know, from submitted and captured diagnosis code throughout the year.
And some of the things that, you know tend to pop up are if there is a high RAF score
that means there is a lot of HCC codes that are being captured.
Doesnít mean that it is not valid, but more likely than not it is something; you know
thatís kind of like needs to be investing in it.
So that will be something that would be a Red Flag to Medicare for a RADV audit if you
have a high number of patients that have more than seven HCCs.
I mean, you know thatís kind of like a standard number that we go with, seven or more.
But, you know, in light of recent advancement with a lot of these health plans that have,
you know been investigated, they might cut that criteria behind and maybe they are going
to say, moving forward, maybe patients that have more than four or five HCCs, they are
going to start looking into.
Thereís just a lot of different, you know factors that are involved, but these are the
top 10 that we want to share with you, high distribution of these HCCs, active versus
history of, thatís you know very important.
There are a lot of problems that happen with these active chronic conditions versus history
of a condition because cancer are those conditions thatís constantly gets miscoded.
Is it active, are they still being treated or is it a history of cancer and so forth.
Now we know that CHF does not go away, we know that COPD does not go away.
So you have to make sure that thatís being recorded and documented accurately.
A major depression is often miscoded, you know, itís not ñ either it is not documented
as major depression or itís just not captured properly or it over-coded and maybe the patient
really does not have major depression.
That seems to happen a lot too.
Protein calorie malnutrition, there are a lot of different rules around coding that
and you have to meet certain criteria in order to code that properly.
You know a lot of times documentation fails because it is just not documented accurately.
It does not mean it does not necessarily exist, but the documentation isnít there to support
the coding out there and reporting out there, you want to say something?
Kim Dues: Yes maíam, I shall do.
Alright, medical ñ aha-ha go ahead.
Holly Cassano: Medicare advantage plans, they have to submit the one best medical record
that supports each HCC identified for validation that of course was changed in 2011 and now
Medicare rollout Medicare Advantage contract system get up to five medical records for
each audited CMS which is per enrollee.
So it is important that that change came about because it really was kind of weighted unfairly
against the Medicare Advantage Plans at that time to only be able to use one medical record.
So it kind of allows the Medicare Advantage Plans to have a better opportunity to sail
throughout the audit compliantly because youíre given more opportunity to prove that those
HCC codes really are accurately reported.
Because sometimes it is hard extrapolating data as we all know from you know, inpatient
record, outpatient records, you know, office records, so it really has a lot about the
playing field, I feel.
And so, a lot of my colleagues now that they have been allowed just to have up to five
Kim Dues: Alright, okay so risk adjustment data validation, RADV, medical record check,
and list of guidance.
CMS created the risk adjustment data validation, medical record check list and guidance.
To assist contracts in selecting appropriate medical records, the guidance is based on
issued payments observed with medical records with previous RADV audits.
The guidance addresses issues observed during intake, incorrect data service, unacceptable
provider type etc., in coding, diagnosis cannot be verified using I-10 guideline.
Holly Cassano: Thatís correct.
Kim Dues: RADV findings.
At the conclusion of the initial medical record review process, results to be issued to audited
contracts in the form of a Preliminary Audit Report of Findings, AROF.
For each audited CMS-HCC the preliminary AROF will detail the validation outcome inner type
if applicable and eligibility for the medical record dispute.
For each enrollee the preliminary AROF will be detailed calculation of the corrected risk
score and payment based upon the initial medical record review results.
Contacts will receive information in this reference on the medical record department,
MRD with the preliminary AROF.
Holly Cassano: Correct.
We have some practice reminders that we like to share with you.
You want to make and at this time reiterate the diagnosis code submitted by Medicare acclaimed
organizations are used to determine beneficiary risk scores which in term determine the risk
Major areas of concern are pointed out to plans to communicate to network providers
in order to reduce or eliminate a fraud abuseand waste in the system.
Some of those reminders are documentation you must always support the codes selected
and substantiate that the proper coding guidelines were followed.
Data validation ensures that those are appropriate.
Up coding or changing diagnosis to obtain higher reimbursement without supporting source
documents is fraudulent.
The risk adjustment diagnosis must be based on clinical medical record documentation from
a face-to-face encounter, must be coded according to the ICD-10 Standard Guidelines for Coding
Assigned based on data service within the data collection period and submitted to the
Medicare advantage organization from appropriate risk adjustment provider type and appropriate
risk adjustment physician data source.
Would you agree?
Kim Dues: Absolutely.
Holly Cassano: Well, weíre concluding, you know this presentation and you know, one other
things that I would like to quote from Socrates and, you know Iíd like to say that the secret
of change is to focus all of your energy not on fighting the old, but on building the new.
So, what I mean by that, you know, I am not going to speak for Socrates, but I am leaving
my own twist on that one, is that basically, you know, there is a lot of things that happened,
you know in the Medicare Advantage System, in the Medicare System, you know, healthcare
overall, that have you know not always been positive and just because a peer gets into
trouble, doesnít mean that, you know, the entire company is fraudulent, or that they
are fraudulent at all.
Same with the provider practice, you know, it should always be innocent until proven
guilty, not guilty until proven innocent.
But sometimes we forget that.
So, instead of focusing on past, you know negative trends or things that have happened
and fighting those old battles, you really need to focus on building a new horizon, you
know within your practice, within your health plan, you know or within yourself.
And what that means is you have to really embrace the changing
And that means leaving the old behind the negative and kind of opening yourself to the
new and embracing, okay we have MIPS, oh my God itís MIPS.
Say okay, you know what MIPS, maybe I can get onboard with that and maybe I can win
You know same with Medicare Advantage.
I did a presentation several years back called winning with Medicare Advantage.
There are ways to, you know not beat the system, but to work with the system compliantly and
synergistically and to get what you need as a provider, as a health plan coder, etc.,
you know what you need and what is currently going on in an healthcare today.
Kim Dues: Thatís right.
And practice to point success in that.
Holly Cassano: Absolutely.
Kim Dues: Making it success.
Holly Cassano: Yeah, so I donít know if we ñ can you open up for questions, Kim
or, you know?
Kim Dues: I think, you know, we pretty much have all those answered.
We have been answering all those questions going along and I think thatís it.
Holly Cassano: Yeah, we would like to thank everyone for attending.
Again this was a free webinar, so we have some other things on our website BillingParadise,
you know that if youíre interested in speaking to us further about risk adjustment, you know
if youíre having any problems within your practice, within your health plans we have
you know a team of specialists including Kim and myself that would be happy to assist you
with any of your needs or any questions, you know if you want to consult with us on something
on how to better capture, you know or to focus on documentation whatever it happens to be.
Please feel free to reach out for us, you know, and we would love to hear from you and
try and help you solve whatever that is, you know happening within your practice or within
We work with all side by side, you know and again, as I said, I help develop the CRC credential
and also a National Exam.
Kim has taken that results and studied diligently and worked with me on many projects including
many auditing projects, government audits, payer audits, you know numerous.
And we work with a lot of attorneys you know BillingParadise really has a great workforce
We do revenue cycle management, healthcare.
Kim Dues: When you have been in it awhile, that is just kind of what happens.
Holly Cassano: Absolutely.
So, again we thank you.
We hope you enjoyed the presentation and if anyone is interested in obtaining a copy of
the PowerPoint just reach out to us on BillingParadise.
Thank you so much and have a wonderful day.
Kim Dues: Thank you so much.
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