00:00
Holly Cassano: Good afternoon.
00:02
My name is Holly Cassano, and I am a CPC, CRC and your host; as well as Kim Dues who
00:12
is also a CPC, CRC.
00:14
We are with BillingParadise and we are here to present to you a free webinar on Risk Adjustment
00:19
Fraud and Not Just Another ìFî Word.
00:24
Hope everyone is doing well today.
00:27
Kim Dues: Good afternoon.
00:29
We are happy to be here.
00:31
Holly Cassano: Yes we are.
00:32
Hope everyone is having a great Wednesday.
00:34
We have almost made it to Friday, at this point.
00:38
Kim Dues: Yes, yes.
00:39
Holly Cassano: Yeah, okay.
00:40
So Kim I am going to just kind of proceed forward, you know some of the things we are
00:46
going to talk about today, you know to help everyone out is, you know that risk adjustment
00:50
is a very confusing topic for many people.
00:53
You know, health plans have trouble with it, you know providers have trouble with it as
00:59
well as coders like ourselves and auditors.
01:01
So, what we are trying to get today is kind of give you a little bit of some basics in
01:06
risk adjustment HCCs overall and then give you some hindsight into RADV Audits and how
01:13
both the health plan providers and coders, you know can help work together so that they
01:20
ensure that they properly are capturing those HCC codes and kind of moving along together
01:25
synergistically.
01:26
Some of you may know me, some of you may not.
01:31
Just to give you a little background.
01:33
I have been in healthcare for a little over 20 years.
01:37
Kim will give you a little bit background on herself, but one other things that I have
01:42
specialized in is risk adjustment.
01:45
And back in 2014, I was approached by the AAPC to help them develop the National Risk
01:53
Adjustment CRC credential and also to help develop the National Exams.
01:59
So we did beta testing and all of that.
02:02
And then in the early 2015, the CRC was finally launched by the AAPC.
02:05
So I was one of the eight people on that National Committee.
02:09
Kim has an extensive background and is also a CRC as I said and has helped me on many,
02:14
many different projects including risk adjustment auditing and so forth.
02:18
Kim, do you want to give a little bit of background about yourselves?
02:23
Kim Dues: Sure, I took the CRC exam and let me tell you it was tough.
02:29
Itís very difficult.
02:30
So, it was a really good exam.
02:31
So, yeah so I have been in healthcare for about 24 years, started out as an insurance
02:36
agent.
02:37
And I literally went door to door selling insurance, got into securities.
02:41
I have a securities license and found my way into healthcare, being that my first time
02:48
being and I am grateful to that man for sure.
02:54
So, I have built and coded many, many specialties, audited.
02:58
I have worked with Holly on several projects and then here we are with BillingParadise.
03:05
And we are talking to you today about Risk Adjustment Fraud, Not Just Another ìFî
03:09
Word.
03:10
Over to you, Holly.
03:11
Holly Cassano: Thatís right.
03:12
Thank you, Kim.
03:13
Yeah, you know those of you who know me on, you know, letís kind of put as much of a
03:18
positive spin on things as possible especially when we are dealing with things like this
03:21
because they do get so intense, you know.
03:23
And there is a lot of fraud that happens sometimes, you know itís abuses more you know not really
03:30
understanding things, and then there is intent to the fraud.
03:35
You know, I always like to try to err on the side if you know possibly that, you know people
03:39
really didnít understand what the rules were, you know I like to not assume that their
03:43
intent was to defraud, you know, weíre never sure.
03:44
And so itís best to kind of assume that it was just a misunderstanding, you know until
03:51
proven otherwise.
03:52
Sometimes people tend to forget that in the scheme of things especially with all the different
03:56
media stuff that we hear, you know about the different health plans, you know which is
04:01
unfortunate.
04:02
I think that sometimes, you know just before we get into it, you know just to give you
04:05
a little insight.
04:06
You know I have talked to a lot of different people in the industry, at health plans ñ worked
04:10
with health plans.
04:11
I worked for a Medicare Advantage Plan myself for several years as well as Cleveland Clinic.
04:16
And, you know even Cleveland Clinic had trouble, struggling as well, did the health plan that
04:22
I worked for in trying to, you know bridge that gap between capturing these HCC codes
04:27
properly, getting documentations all line up, you know with the family providers and
04:32
in submitting things into wraps and now we have EBS [Phonetic] [0:04:34] also in the
04:34
mix.
04:36
So one of the things I would like to say is that, you know we know that Medicare performs
04:41
risk adjustment validation audits a lot of you have provided medical record documentation,
04:45
which helps validate, you know submit the diagnosis codes, as they correlate to HCC
04:51
codes.
04:52
Some of the health findings we have seen recently in headlines of United Healthcare, Freedom
04:55
Health, which is you know, in Florida where I am, Humana, Aetna, Optimum Healthcare and
05:00
then they have all, you know unfortunately fallen under the scope of the DOJ for allegedly
05:06
submitting risk adjustments scores that improperly inflated Medicare advantage reimbursement,
05:09
and that was from HealthLeaders Media that they recently reported on that.
05:14
I am not saying either way, Iím just reporting what, you know the headlines that I have seen.
05:20
You know and things that I know.
05:22
You know there are a lot of struggles that are going within health plan trying to get
05:26
this data.
05:27
And for those of you that are participating, that work for a health plan here today or
05:31
that participate from a providerís office, you really need to work together, you know
05:35
as a team to kind of, you know help each other to capture the data, because at the end of
05:40
the day, itís really about your patients and about their health.
05:43
And you need to make sure that youíre reporting these chronic conditions accurately to your
05:49
health plans so that they can report them accurately to Medicare and get proper reimbursement
05:54
not just for themselves or for you guys in provider practices, but overall so that they
05:59
can provide better benefits to those members.
06:02
And one of those ñ one day soon we are all going to be one of those members of a health
06:06
plan.
06:07
So we want to make sure that we are taking it right now, right Kim?
06:10
Well, taking away now to make sure that, you know we can really understand how risk adjustments
06:15
works because at the end of the day with value-based care and everything thatís changing in healthcare
06:21
today in the landscape its really going to end up more or less into some type of risk
06:25
adjustment model where we have to capture these chronic conditions thatís what Medicare
06:29
and PQRS attempted it.
06:31
Kim Dues: Absolutely.
06:33
Female Speaker: Absolutely.
06:34
Holly Cassano: You know thankfully, thatís some setting, but now we have MIPS, you know
06:38
that we have to deal with, but you know
06:39
Kim Dues: Itís got to be a team effort inside that office.
06:40
It canít be ñ the team has to create a provider query process.
06:47
There are plenty of ìprovider queryî forms out there for you to alter to fit your office
06:57
and what a provider query process is about is not telling a provider how to diagnose.
07:02
Holly Cassano: Correct.
07:03
Kim Dues: Itís trying to get the provider to dig further into the patientís health
07:12
and give a specified diagnostic code, so that it meets a medical necessity.
07:18
And then, if the patient has conditions that will link ñ to link those conditions so
07:26
that, you know they are going to feed into HCC.
07:29
Holly Cassano: Right, so just to kind of cover, you know some basics again for those you who
07:34
might be new to this industry with Medicare Advantage Risk Adjustment and HCCs, you know,
07:39
trying to give more background on that.
07:42
For those of you who may not know, you probably may hear several phrases, one of them being
07:47
Risk Adjustments Factor score or RAF, when properly recorded.
07:51
And what that does, it allows CMS to provide additional reimbursements to Medicare Advantage
07:56
Plans, based as I was saying on membersí overall health.
07:58
The RAF scores, are derived from the submitted diagnoses from what should be in the medical
08:03
record.
08:04
And a higher weighted RAF ñ RAF excuse me, correlates to sicker patients, which means
08:09
a higher cost in the Medicare Advantage Plan to treat these sicker patients, hence that
08:12
means it requires higher reimbursement back to the MA plans in CMS.
08:18
The main avenue in which Risk Adjustment Fraud and Abuse occurs, is by recording chronic
08:22
conditions and subsequent treatment, on patients that either did not have the reported conditions
08:27
or care, or upcoding on existing conditions, to make it seem more severe in nature than
08:31
it is.
08:32
And what I mean by that is letís say if a patient has diabetes and then maybe they
08:36
have, you know some neuropathy or something like that or ñ and ñ or itís not really
08:42
related but someone might, you know decide to casually relate it when they report it,
08:49
not necessarily itís documented that way obviously but they might, you know happen
08:52
to do that.
08:53
I am not saying they are doing it with intent, but it does happen you know just an error.
08:59
But those are things that we want to watch out for.
09:03
A little overview about CMSís Hierarchical Condition Categories or HCCs.
09:08
You know, Medicare actually introduced them back in 2004 and the goal was to pay the Medicare
09:15
Advantage and prescription drug plans accurately and fairly by adjusting payments from rolling
09:19
based on their demographics and their healthstatus.
09:20
The Risk Adjustment Payment model basically measures the disease burden that include 70
09:26
HCCs, which are correlated to diagnosis codes, an accurate diagnosis code documentation of
09:32
the ICD-10s and formerly ICD-9s and recording now determines reimbursement needs.
09:37
You know, roughly about 8,700 ICD-10 codes that mapped to one of 70 HCCs, and mostly
09:43
chronic, but some are acute and previously in ICD-9 we had about 3600, right Kim?
09:48
You want to go with that perhaps?
09:51
Kim Dues: Yes.
09:52
Yeah, right.
09:53
Will you do the next one?
09:54
Holly Cassano: Uh-mmm.
09:55
Kim Dues: So we got right, if you want to talk about the process?
09:58
Holly Cassano: Yeah, letís talk about the process a little bit and then I am going to
09:59
hand it over to you for a couple of files.
10:01
[Coughs] Excuse me.
10:03
Kim Dues: Okay.
10:04
Sounds good.
10:05
Holly Cassano: Yeah, thank you.
10:07
Kim Dues: Okay so the process the member face-to-face.
10:12
Care and Diagnosis are documented in the page progress notes, ICD-10 codes are submitted
10:19
on claims based on face-to-face encounter with clinical findings, claims data, diagnosis
10:23
codes are converted to HCC codes.
10:27
HCC data submitted to CMS, CMS calculates the Medicare Advantage Risk Adjustment Plan
10:38
and providers can deliver ñ and so at the end of the plan and the providers can deliver
10:44
better care and reimbursement is received.
10:46
Holly Cassano: Thatís correct.
10:48
Kim Dues: Um-hmm.
10:50
Holly Cassano: The next slide that I added is the payment run dates, and just to kind
10:57
of briefly go over that, you know, Kim this.
11:00
Kim Dues: Thatís okay, go ahead.
11:02
Holly Cassano: I just want to try and mention it briefly because it changed this year or
11:07
well actually, last year in April 2016, those of you who know, already have seen this but
11:13
for those who have not CMS issued a memo on April 20, 2016 and they changed around the
11:19
deadline for submitting risk adjustment data for using the risk code calculations payment
11:25
runs for 2016, 2017, 2018.
11:28
And what the overall message in that was that they finally decided that they were going
11:31
to be planning risk for us.
11:33
For 2016 they used 10% of the risk for calculating the diagnosis from accounted data and fee
11:38
for service.
11:39
Some with ñ 90% [Phonetic] [0:11:41] of the risk were calculated with diagnosis from
11:43
RAFs and fee for service.
11:45
Then, as of this year there is a 25% risk for calculated diagnoses from accounted data
11:51
fee for service.
11:52
Some of the 75% of the risk were calculated diagnosis from RAFs and fee for service and
11:57
then itís going to continue on and increase in that percentage as we progress through
12:02
in the coming year.
12:04
So, just to what people know, if anyone wants that information just contact me afterwards
12:10
or Kim and we are happy to send it to you.
12:14
Kim Dues: Sure.
12:15
Holly Cassano: Kim, do you want to take payment methodology?
12:19
Kim Dues: Absolutely.
12:21
Payment Methodology: Payments are based upon acuity of diagnosis, sicker payments ñ patient
12:27
will require more active resources.
12:29
The diagnoses must be reestablished each year to ensure that next yearís payments will
12:37
cover the cost.
12:38
For example an amputation must be reported at least once per year to ensure that services
12:43
related to this condition will be covered.
12:46
So every year they have to say in the environments that this person is an amputate, and the details
12:55
of the amputate.
12:56
Documentation is must for the diagnosis that are reported and plan for each diagnosis.
13:03
So the plan of care has to be spelled out for each diagnosis.
13:10
Often times physicians get familiar with patients overtime and neglect documentation on stable
13:17
conditions.
13:18
Okay.
13:19
Holly Cassano: Yeah.
13:20
Just to speak to that a little bit further, you know often times, you know when I ñ especially
13:25
when I worked for the Medicare Advantage Plan for several years I had about, I had three
13:31
counties, so I had about 150 providers that were mine those to visit.
13:36
And so I would go through tons of medical records and, you know look for different things,
13:41
trying to see, you know if there is any puzzle or linking statements between conditions especially
13:46
with diabetes and CKB and CHF, etc.
13:50
But, one of the biggest things that I used to see that would be forgotten in documentation
13:55
annually especially in the first quarter, you know when those patients may need a firm
14:00
initial.
14:01
Annual wellness visit, if theyíre a new patient or if itís their subsequent annual
14:04
wellness visit is, you know I could see some from the prior year we have statistics to
14:09
look at but, you know say, Mr. Jones, you know he had a below-knee amputation in left
14:13
knee, alright?
14:14
And then, you know in the year before, I mean we were reporting that accurately, but then
14:21
in the following year somehow magically, you know we just missed, you know knee came back.
14:25
And so we were always wondered how did that happen, you know thatís one of my favorite
14:30
examples.
14:31
But it happens all the time and itís not intentional, itís just a, you know the doctors
14:34
are very overwhelmed, you know they got a lot of patient that they have to see.
14:38
You know, now they have MIPS, you know for their PQRS, theyíve made full use.
14:41
They have all these different things they are trying to capture just for straight Medicare
14:46
and then also now we have the Medicare Advantage plans coming along.
14:49
Weíre saying okay, oh we need your HEDIS measures, which weíre not going to give
14:53
it you today, thereíll be another one.
14:55
But you know, but we need you to help us capture these chronic conditions and, you know one
15:00
of them that I always see, you know left off the board was the amputations.
15:04
You have things like that, or any kind of status condition.
15:07
So itís really important to make sure that you capture your status conditions.
15:10
They say annually, Medicare says annually, I always recommend at least twice a year to
15:15
cover your bases and I recommend at least once in the first quarter, you know to check
15:20
the chronic conditions of all your patients and then again in like the third or fourth.
15:24
You know Medicare has all the different payment runs throughout the year.
15:27
So you want to make sure that you capture them within those payments runs.
15:31
So, thatís my recommendation and advice.
15:33
Kim Dues: Well, you know let me add to that.
15:36
The other things is inside that EMR.
15:37
You have to make sure that you as you go forward seeing this patient you need to make sure
15:46
that youíll designate active and conditions that are closed out.
15:54
So, Holly and I see that all the time when we
15:59
We saw that, you know they have a list of 35 diagnoses and 35 different problems and
16:07
they all are active.
16:08
Well, that canít be.
16:09
You have to bring it down and make sure that ones that are active are active and the ones
16:16
that are resolved are resolved.
16:17
Holly Cassano: Correct.
16:18
Kim Dues: Yeah and we all know that you canít code from problem list, you can confirm from
16:24
a problem list, but they have to make sure they address it in your assessment plan or
16:29
you know somewhere in those notes confirming those conditions and ñ
16:32
Holly Cassano: Right.
16:33
Kim Dues: Yeah.
16:34
Out on Facebook the other day there somebody was talking about coding from lab results.
16:41
Do you want to speak to that?
16:43
Holly Cassano: Yeah, yeah.
16:44
Thatís a big no, no.
16:45
Kim Dues: I know, it is a good one.
16:47
Holly Cassano: Yeah itís, you know itís unfortunate you know.
16:52
But sometimes, you know people get different information, I mean, just like youíre receiving
16:55
information from us today.
16:58
You know, so itís ñ sometimes itís data overload.
17:01
You know maybe there are too many courses out there.
17:03
I donít know, but just to make sure that you know if you are a coding professional
17:08
or provider of health plan etc., that you just validate your information.
17:13
We will have, you know this PowerPoint available so ñ post webinar and, you know I always
17:19
put links too, you know where my source of documentation comes from.
17:23
So, itís easy to check, but you know itís very important to make sure that, you know
17:28
you are following the guidelines.
17:29
Medicare published a book basically itís a risk adjustment bible back in 2008, And
17:35
you know there is still a lot of people that arenít aware if that exists.
17:38
They have updated it to some extent, you know periodically over the course of time, but
17:43
they really need to do a full overall.
17:45
I think they are just waiting on some different things, you know in government to do so.
17:51
But, at some point they will probably redo the entire book.
17:54
Kim Dues: Yeah correct.
17:55
Holly Cassano: But that is, you know that is ñ that really is, you know the bible
17:58
and you can go through the updates that have come out subsequent to 2008 to check things.
18:04
But if you have any questions thatís your best bet and also going to the Medicare website
18:08
for Risk Adjustment, which we will give you post webinar.
18:12
Next we want to talk about a little bit about HCC Payment Methodology and ICD Coding a little
18:19
bit further, you know documentation.
18:23
Physicians really need to ensure that they are really paying attention to their documentation
18:27
and make sure that contains the necessary details, the staff members can choose the
18:31
right codes for each patient with that provider.
18:35
Besides the increased specificity of a diagnostic code, the doctors also face other documentation
18:40
challenges including identification of conditions that contribute to the complexity of a disease,
18:46
severity of contributing morbidity, co-morbidity, current stage of the disease such as chronic
18:50
kidney disease, dementia and asthma, type of diabetes and itís very ñ and a prehistory
18:55
of any present illness and follow up visits.
18:58
You know, that physicians at the end of the day are the ones responsible for choosing
19:03
the correct diagnosis codes, so I want to make sure I am clear on that.
19:06
We want to say that staff members can choose things because staff members when they are
19:10
taking, you know the intake information and so forth or if you have a scribe that works
19:15
for you, you want to make sure that they are selecting the proper conditions, but you at
19:19
the end of the day as a provider have to double check that information to make sure that it
19:23
is captured correctly, okay?
19:24
Kim Dues: Alright.
19:25
Holly Cassano: Alright, letís continue.
19:26
Kim, you want to take coding changes?
19:27
Kim Dues: I am sorry?
19:28
Holly Cassano: Do you want to take coding changes, with ICD-10 and diabetes?
19:33
Kim Dues: Sure, sure.
19:35
Holly Cassano: Very good.
19:37
Kim Dues: Current changes for ICD-10, diabetes communication must
19:43
include the type of diabetes.
19:45
How about that?
19:47
We would love to see whether it is I or II, right?
19:52
We have to see.
19:53
Body system affected, the complication and manifestation.
19:57
If a patient with type II diabetes is using insulin, a secondary code for long-term insulin
20:04
is required.
20:05
Neoplasmís documentation must include first of all the type, malignant, is it primary,
20:12
secondary, is it cancer in situ, benign, uncertain, unspecified behavior, the location, I mean
20:17
the site of the malignant neoplasm.
20:22
If malignant any secondary site should be determined, laterality on papers.
20:34
Asthma documentation must include the severity of the disease, mild ñ intermittent, mild
20:40
ñ persistent, moderate ñ persistent.
20:42
So these are drilling down into these conditions.
20:46
I-10 was lotís of advance specific codes, thatís over.
20:51
We have to move on and drill down into these codes.
20:53
Holly Cassano: Absolutely, I mean just, you know, if youíre going over those, you know
20:57
what I am saying it came to mind for me is that, you know now with ICD-10 there is over
21:02
200 ICD-10 codes just for diabetes alone.
21:04
So, the specificity is really a primary concern for any provider including professional and
21:12
also auditor.
21:13
The other things you want to keep in mind too, you know in the event of a RADV audit,
21:18
you know, you know if you are not being specific and drilling down as Kim said, into your notes
21:24
youíre going to get dinged in a RADV audit.
21:25
So, we are going to get into that very shortly, but again we just want to give you some of
21:30
the basic overviews of whatís going on.
21:33
One thing that I would like to mention is the HCC coding impact to revenue.
21:40
And what basically I am saying about that is that, you know letís say you had a 76-year-old
21:47
female or whatever one male and, you know for a 76-year-old female, you know they captured
21:54
a low level of specificity so at the end of the day she actually had diabetes, she had
22:01
vascular disease, she had CHF, annular disease interactions.
22:04
But at the end of the day they didnít capture any of that.
22:07
The total RAF score for that is 0.588 or ñ as of the stats.
22:12
And then some conditions coded moderate level specificity with same 76-year-old female would
22:17
be ñ and she is Medicaid eligible.
22:20
Diabetes with vascular complications, vascular disease without complications, but they missed
22:25
CHF and they missed the disease interactions.
22:27
So then you get a RAF score for 1.005, and then if you have someone ñ same 76-year-old
22:36
female with a high level of specificity where she also is Medicaid eligible they did capture
22:42
again the diabetes with vascular complications, vascular disease with complications, arteriosclerosis,
22:47
with ulcers et cetera, CHF and you have captured disease interaction then the total RAF score
22:54
there is 2.919.
22:56
And what that means is when you have no conditions coded, as in the first example that revenue
23:02
payback to the health plan is $528, but when you have all of the conditions coded properly
23:10
and captured you get revenue back to the health plan from Medicare of $2624.
23:14
Thatís a significant difference.
23:17
And again itís not just about the money thatís not weíre trying to drive home
23:21
here.
23:22
We are trying to drive home here that when you accurately capture these chronic conditions
23:27
not only does it increases the RAF score appropriately and compliantly, but it also tells Medicare
23:33
this patient is really sick and that the plan needs the money in order to pay for the care
23:38
of this patient and thatís how you capture those compliantly and correctly.
23:42
But itís all about documentation.
23:44
So that something that, you know requires you really need to look at along with your
23:48
coders and auditors and health plans.
23:50
You know, the health plans needs to double check to make sure that what the providers
23:52
are submitting, whether they are capitated or partially ñ partial risk or future service,
23:58
you know however if itís commercial plan that these diagnoses are being captured correctly,
24:04
and that the documentation support that is being submitted at the end of the day.
24:11
There are a couple of questions to consider regarding physician documentation and basically
24:18
what you can say about the medical record is that, it really is the clinical life story
24:22
of that patient.
24:23
So one must ask themselves does the documentation paint a complete picture of that patientís
24:28
condition and if you canít answer that with a firm yes, then you need to go back to the
24:34
beginning and take a look at what has been captured in that patientís clinical life
24:38
story.
24:39
Would we say so Kim?
24:42
Kim Dues: Absolutely I do, for sure.
24:47
Holly Cassano: Okay, documentation you know, again you want to properly reflect the memberís
24:54
health status, you know for the plans you want to fully assess all chronic conditions
24:58
at least annually.
24:59
And again, like I said I recommend at least twice thoroughly document in the chart
25:03
[0:25:03:29] notes, all conditions evaluated with each visit and code to the highest level
25:07
of specificity, just a reminder.
25:11
We have some top ten issues with documentation and I call them the top ten fails in documentation.
25:18
Number one is failing to capture HCCs at least once every 12 months which, you know, I
25:25
[0:25:25] holding us, as youíll hear throughout this entire presentation.
25:28
I would say, you know bulletproof your documentation is one of my favorite sayings.
25:33
Failure to ensure the medical records obtains a legitimate signature with credential, for
25:37
example, to determine whether such as the electronic health record was unauthenticated
25:41
not electronically signed.
25:43
They need to ensure the diagnosis thatís being billed and the actual medical record
25:47
documentation match.
25:48
Failure to document according to the need principles, which weíll get into.
25:53
Diagnosis needs to be monitored, evaluated, assessed, addressed and treated.
25:56
Failure to annually document status decodes in chronic conditions.
26:00
Failing, to use a linking statement or document a causal relationship from
26:05
[0:26:06] codes.
26:06
Failing to add any diagnosed HCCs or RxHCCs prescription drug HCCs thatís what those
26:12
are, to both the chronic problem list in the acute assessment.
26:15
Failing to evaluate each of the HCCs, RxHCCs on a semi-annual basis or updates; failing
26:20
to review all specialist documentation related to cardiology and master discharge summaries,
26:25
radiology specialties correspondence pulmonary.
26:28
Epicardial graphs, x-rays, lab results and previous encounters and finally failing to
26:33
submit more than the standard four ICD-10 codes.
26:37
You want to make sure that, you know Medicare now accepts 12, you want to make sure that
26:44
your clearinghouse can facilitate that from a provider standpoint, and most of the plans
26:49
are assumed and I hate to use that word, but you know, in line with that now and are looking
26:55
for more than those four standard ICD-10 codes.
26:59
So if you are not submitting more than four when they are present, you know, chronic conditions
27:07
then you need to look into not with your clearinghouse and make sure that they can accept that, because
27:11
your social clearinghouse is out there that ñ and EHRs that do not allow the provider
27:16
to transmit, you know more than the standard four.
27:23
Right actually, that was one of the big pushes with auto clearinghouse to get that done or
27:29
same as guidance, so they should definitely be able to put up to 12.
27:35
Holly Cassano: At minimum, yes.
27:37
Kim Dues: Itís 12.
27:39
They should be able to put up to 12.
27:42
That was the guidance that was given to the clearinghouses.
27:47
So if you have a process in your billing department where your coders code and then the information
27:55
goes to data entry, data entry needs to understand, they need to put in every single diagnosis
28:01
code, not just four.
28:04
So make sure data entry is understanding that that is what they are required to do.
28:09
Holly Cassano: Correct.
28:11
Kim Dues: Absolutely, because thatís another thing we have seen as we have been in travels
28:17
in an outsider, EMR systems and doctorís offices.
28:21
Holly Cassano: And all the information I am sharing with you are just the basics, is all
28:25
part and parcel of making sure that that medical record is bulletproof in the event of an RADV
28:31
audit.
28:32
One of the other things that we will touch on is the annual wellness visit.
28:35
Itís very difficult for Medicare Advantage Plans to get providers to comply with that
28:42
annual wellness visit because it is not mandatory.
28:44
However, what it mandatory on an annual basis is the HRA.
28:49
So, what needs to happen is to have a partner relationship between the Medicare Advantage
28:56
Plans and the provider practices and help the practices, you know get in line with getting
29:03
Medicare patients in to do their annual wellness visit and their health related assessment.
29:08
So, you know, that is something that needs to be worked on, but there are a lot of different
29:12
components to the annual wellness visit, but once your practice gets in the line with doing
29:16
them and designating, maybe one or two mid-levels in your practice to perform those, thatís
29:22
really the best way to utilize, you know your mid-levels with the annual wellness visits
29:27
for that particular function.
29:29
So, I would recommend looking into that if you are not currently providing annual wellness
29:35
visits and HRAs in your practice, you really need to look into that.
29:39
Especially, if you are participating with Medicare Advantage Plans because one other
29:43
things that can happen, you know, especially if you are not performing well on your HEDIS
29:49
measures, if your RAF scores are low because you are just failing to capture these chronic
29:53
conditions.
29:54
There is a thing within the plans, then I know because I work for one called ìright
30:01
sizing your network.î
30:02
And I say it in quotes because itís something that is not very pleasant to say, but Kim
30:08
as meanwhile and most of the people that know me, you know, thatís something that I talk
30:11
about.
30:12
And what I mean by that, is that, when you have a provider that is poorly performing
30:16
in your network and you are the Medicare Advantage Plan, you try to do go out, you try to assess
30:22
what the problem is, you try to offer assistance to that provider practice to see what the
30:27
issues are with them capturing the chronic conditions.
30:30
Maybe, it is an issue with documentation, maybe it is an issue with staff, maybe it
30:34
is an issue with coverage, maybe it is an issue with just on understanding what needs
30:40
to take place for Medicare Advantage Plans and have, and they donít really understand
30:44
what HCC codes are.
30:46
Because it is slightly different than the documentation that it captures and ready to
30:49
use for service, but my standard is this.
30:52
If you understand how to document for Medicare Advantage, pretty much you are going to cover
30:58
yourself in any type of situation because it is so much more involved and if you understand
31:02
PQRS and MIPS documentation and then you pretty much going to be overlooked for your documentation
31:08
and you wonít ever have to worry about being right size to every network.
31:11
Kim Dues: Alright.
31:12
And with that said ñ and with that said, each practice should have a meeting minimum
31:21
twice a month with all the providers, with the medical director and they should go over
31:27
their documentation as they look out what the coders are giving back to them.
31:33
Holly Cassano: Correct.
31:35
Kim Dues: So, this query process is a big circle.
31:41
And so, that should have meetings with the billing department, go over the queries, the
31:47
doctors needs to look at their documentation, review, have the conversations and figure
31:52
out where the holes are because it is going to be about the mid-levels choosing the highest
31:59
specified code for the patientsí condition and then that documentation needs to match.
32:07
And furthermore what we really care, you know I think Holly and I are probably going to
32:13
do something separate on the annual wellness visit.
32:16
What do you think about that Holly?
32:18
Most likely.
32:19
Because itís such a big topic and how to use the guidance for Medicare properly and
32:27
not only the coding, to follow their guidance from a 10 code, that meet medical necessity.
32:36
So anyway, it really is about the whole company, the whole practice tightening up their process.
32:44
Holly Cassano: Correct.
32:45
Alright, so letís move on.
32:48
You know, I think weíve hammered a lot of that tone, for most people, you know and again
32:53
if there are any questions about any of this material post, you know webinar just feel
32:57
free to contact us and we will be happy to respond.
33:01
Letís kind of get into the second half of this as we head down towards the finish line.
33:07
You know the CMS-RADV audits, you know I like to say, a lot of people are like, what?
33:14
Whatís a RADV audit?
33:15
They have heard of audits, they have heard of Medicare audits, but when it comes to RADV
33:18
unless they really understand what risk adjustment is and HCC codes they really have never heard
33:23
of RADV.
33:24
So, you know that RADV stands for Risk Adjustment Data Validation audits.
33:27
It is a method of evaluating and validating the accuracy of the diagnosis and a different
33:33
payment part of plan.
33:34
Itís a proactive action to help reduce the Part C error.
33:37
And each year CMS reports the actual payment error estimates, that comply with the Improper
33:42
Payments Elimination and Recovery Act which is called IPERA, and that started in 2010.
33:46
We have a link to that if you ever want to check it out, just let us know.
33:51
And CMS expects that RADV will have a pretty much sentinel effect on the quality of risk
33:56
adjustment data submitted for payment going forward into the healthcare continuing with
34:00
value based care payments and overall management of chronic care.
34:04
And here ñ hence, you know the outcome of MIPS and MACRA.
34:07
Kim, do you have anything youíd like to add to that?
34:10
Kim Dues: No, I think thatís.
34:11
I think thatís spot on, I think itís perfect the way that you went through that.
34:16
Holly Cassano: Yeah.
34:17
A little bit more about RADV audits for those of you that donít fully know.
34:24
CMS audit ensures the integrity and accuracy of the risk adjusted payment.
34:29
It verifies as I said the diagnosis that is submitted by the Medicare Advantage Plan and
34:34
that itís supported by the medical record documentation for that specific member.
34:39
Medicare plans can be selected for RADV audits annually and the selected Medicare Advantage
34:43
Plans are required to submit member medicalrecords to evaluate the diagnosis data previously
34:47
reported CMS.
34:49
Provider should also be aware of RADV audits because providers are required to assist the
34:53
MA plan by providing medical record documentation for members considered in the audits.
34:58
A lot of providers donít really know that or they are not aware of that and they think,
35:03
you know, but sometimes, you know, that will just ñ you know, if you work for Medicare
35:08
Advantage Plan, this is kind of some of the adjectives that I would get and I donít
35:11
mean that negatively, but itís a misunderstanding on the provider part.
35:15
That weíre just out there really trying to come into your office or we asked for medical
35:19
records itís just really all money to the plan.
35:21
But again, I want to stress that on behalf of the plans and having worked on both sides
35:27
of the fence.
35:28
That is not just about money back to the client.
35:31
It is about making sure that the system is operating compliantly and correctly and effectively
35:38
in keeping costs down by accurately reporting all these chronic conditions and making sure
35:44
that the medical record properly supports those conditions that are reported because
35:48
Medicare does audit as we know.
35:51
So ñ and if it is not documented what do we say.
35:54
Itís not done.
35:55
Kim Dues: Not done.
35:56
Holly Cassano: You may have mentally done it, or talked about it or something, but if
36:00
as a provider you donít actually document it and there is no way to prove that this
36:05
was, you know done and performed that it really exist or that you did tests and hereís the
36:10
result, the patient has COPD etc.
36:11
So, itís a check and balance system.
36:12
So anyway, Kim you have anything you would like to add to that?
36:15
Kim Dues: No, I think that is very accurate again.
36:23
Itís great.
36:24
Holly Cassano: Okay.
36:26
CMS part of revenue process, as CMS request records that are based on enrolment data for
36:31
January as payment year and that plus eligible enrollees partly
36:36
during the data collection year, full risk continuously enrolled in the same.
36:41
Contract from January of the data collection year through January of the payment year.
36:44
Non-ESRD in status from the January of the data collection year through the January of
36:49
the payment year.
36:50
Non-hospice only starts from January of the data collection year through the January of
36:54
the payment year and at least one CMS-HCC assigned, all CMS-HCCs for selected enrollees
36:59
will be overviewed.
37:00
So thatís the standard process.
37:03
Then they do the medical record review, and the record submitted for the RADV, first undergo
37:08
an intake evaluation.
37:10
For outpatient physician records, the CMS generated attestation maybe similar with the
37:15
record thatís missing with provider signature and work credential and only valid records
37:19
go forward for coding.
37:21
Kim Dues: Thatís right.
37:23
Holly Cassano: Medicare advantage organizations managed risk adjustment diagnosis must be
37:27
based on clinical medical record documentation, get on face-to-face encounter, patient and
37:32
provider, coded in accordance with ICD-10 Standard Guidelines for Coding and Reporting.
37:37
Assigned based on need to service within the data collection period and submitted to the
37:41
Medicare Advantage contract for acceptable risk adjustment provider type, risk adjustment
37:44
provider data source.
37:45
Anything you want to say about that Kim?
37:47
Kim Dues: No, I will take the next one.
37:51
Top 10 RADV Red Flags, members with seven or more HCCs.
37:57
Holly Cassano: I love that.
37:59
Kim Dues: Members with plus 1 in RAF score from prior year, top 1/3rd paying stratum
38:09
diagnosis HCC, RxHCC, high distribution HCCs, active versus history of vascular disease,
38:21
diabetes with complications, major depression, protein calorie malnutrition, more than one
38:29
status code per member.
38:31
Okay.
38:32
Holly Cassano: Yeah.
38:33
I would like to speak to that a little bit and thank you for sharing that.
38:36
Yeah, often times you know Medicare Advantage Plans as well as Medicare they extrapolate
38:43
data, you know, from submitted and captured diagnosis code throughout the year.
38:47
And some of the things that, you know tend to pop up are if there is a high RAF score
38:52
that means there is a lot of HCC codes that are being captured.
38:55
Doesnít mean that it is not valid, but more likely than not it is something; you know
39:00
thatís kind of like needs to be investing in it.
39:04
So that will be something that would be a Red Flag to Medicare for a RADV audit if you
39:09
have a high number of patients that have more than seven HCCs.
39:13
I mean, you know thatís kind of like a standard number that we go with, seven or more.
39:20
But, you know, in light of recent advancement with a lot of these health plans that have,
39:25
you know been investigated, they might cut that criteria behind and maybe they are going
39:29
to say, moving forward, maybe patients that have more than four or five HCCs, they are
39:33
going to start looking into.
39:36
Thereís just a lot of different, you know factors that are involved, but these are the
39:40
top 10 that we want to share with you, high distribution of these HCCs, active versus
39:46
history of, thatís you know very important.
39:48
There are a lot of problems that happen with these active chronic conditions versus history
39:54
of a condition because cancer are those conditions thatís constantly gets miscoded.
39:59
Is it active, are they still being treated or is it a history of cancer and so forth.
40:06
Now we know that CHF does not go away, we know that COPD does not go away.
40:11
So you have to make sure that thatís being recorded and documented accurately.
40:16
A major depression is often miscoded, you know, itís not ñ either it is not documented
40:22
as major depression or itís just not captured properly or it over-coded and maybe the patient
40:30
really does not have major depression.
40:32
That seems to happen a lot too.
40:34
Protein calorie malnutrition, there are a lot of different rules around coding that
40:38
and you have to meet certain criteria in order to code that properly.
40:40
You know a lot of times documentation fails because it is just not documented accurately.
40:45
It does not mean it does not necessarily exist, but the documentation isnít there to support
40:49
the coding out there and reporting out there, you want to say something?
40:54
Kim Dues: Yes maíam, I shall do.
40:58
Alright, medical ñ aha-ha go ahead.
41:01
Holly Cassano: Medicare advantage plans, they have to submit the one best medical record
41:06
that supports each HCC identified for validation that of course was changed in 2011 and now
41:13
Medicare rollout Medicare Advantage contract system get up to five medical records for
41:17
each audited CMS which is per enrollee.
41:21
So it is important that that change came about because it really was kind of weighted unfairly
41:25
against the Medicare Advantage Plans at that time to only be able to use one medical record.
41:31
So it kind of allows the Medicare Advantage Plans to have a better opportunity to sail
41:38
throughout the audit compliantly because youíre given more opportunity to prove that those
41:43
HCC codes really are accurately reported.
41:46
Because sometimes it is hard extrapolating data as we all know from you know, inpatient
41:51
record, outpatient records, you know, office records, so it really has a lot about the
41:56
playing field, I feel.
41:57
And so, a lot of my colleagues now that they have been allowed just to have up to five
42:02
medical records.
42:03
Kim Dues: Alright, okay so risk adjustment data validation, RADV, medical record check,
42:11
and list of guidance.
42:13
CMS created the risk adjustment data validation, medical record check list and guidance.
42:18
To assist contracts in selecting appropriate medical records, the guidance is based on
42:23
issued payments observed with medical records with previous RADV audits.
42:29
The guidance addresses issues observed during intake, incorrect data service, unacceptable
42:36
provider type etc., in coding, diagnosis cannot be verified using I-10 guideline.
42:44
Holly Cassano: Thatís correct.
42:47
Kim Dues: RADV findings.
42:51
At the conclusion of the initial medical record review process, results to be issued to audited
42:56
contracts in the form of a Preliminary Audit Report of Findings, AROF.
43:02
For each audited CMS-HCC the preliminary AROF will detail the validation outcome inner type
43:11
if applicable and eligibility for the medical record dispute.
43:15
For each enrollee the preliminary AROF will be detailed calculation of the corrected risk
43:21
score and payment based upon the initial medical record review results.
43:27
Contacts will receive information in this reference on the medical record department,
43:32
MRD with the preliminary AROF.
43:34
Holly Cassano: Correct.
43:36
We have some practice reminders that we like to share with you.
43:40
You want to make and at this time reiterate the diagnosis code submitted by Medicare acclaimed
43:46
organizations are used to determine beneficiary risk scores which in term determine the risk
43:51
adjusted reimbursement.
43:52
Major areas of concern are pointed out to plans to communicate to network providers
43:56
in order to reduce or eliminate a fraud abuseand waste in the system.
43:59
Some of those reminders are documentation you must always support the codes selected
44:04
and substantiate that the proper coding guidelines were followed.
44:08
Data validation ensures that those are appropriate.
44:10
Up coding or changing diagnosis to obtain higher reimbursement without supporting source
44:15
documents is fraudulent.
44:17
The risk adjustment diagnosis must be based on clinical medical record documentation from
44:21
a face-to-face encounter, must be coded according to the ICD-10 Standard Guidelines for Coding
44:25
and Reporting.
44:26
Assigned based on data service within the data collection period and submitted to the
44:31
Medicare advantage organization from appropriate risk adjustment provider type and appropriate
44:36
risk adjustment physician data source.
44:37
Would you agree?
44:39
Kim Dues: Absolutely.
44:40
Holly Cassano: Well, weíre concluding, you know this presentation and you know, one other
44:48
things that I would like to quote from Socrates and, you know Iíd like to say that the secret
44:55
of change is to focus all of your energy not on fighting the old, but on building the new.
44:59
So, what I mean by that, you know, I am not going to speak for Socrates, but I am leaving
45:04
my own twist on that one, is that basically, you know, there is a lot of things that happened,
45:10
you know in the Medicare Advantage System, in the Medicare System, you know, healthcare
45:14
overall, that have you know not always been positive and just because a peer gets into
45:20
trouble, doesnít mean that, you know, the entire company is fraudulent, or that they
45:23
are fraudulent at all.
45:25
Same with the provider practice, you know, it should always be innocent until proven
45:30
guilty, not guilty until proven innocent.
45:32
But sometimes we forget that.
45:33
So, instead of focusing on past, you know negative trends or things that have happened
45:40
and fighting those old battles, you really need to focus on building a new horizon, you
45:46
know within your practice, within your health plan, you know or within yourself.
45:53
And what that means is you have to really embrace the changing
45:57
healthcare today.
45:58
And that means leaving the old behind the negative and kind of opening yourself to the
46:03
new and embracing, okay we have MIPS, oh my God itís MIPS.
46:08
Say okay, you know what MIPS, maybe I can get onboard with that and maybe I can win
46:12
with MIPS.
46:13
You know same with Medicare Advantage.
46:14
I did a presentation several years back called winning with Medicare Advantage.
46:18
There are ways to, you know not beat the system, but to work with the system compliantly and
46:25
synergistically and to get what you need as a provider, as a health plan coder, etc.,
46:30
you know what you need and what is currently going on in an healthcare today.
46:35
Kim Dues: Thatís right.
46:37
And practice to point success in that.
46:40
Holly Cassano: Absolutely.
46:41
Kim Dues: Making it success.
46:42
Holly Cassano: Yeah, so I donít know if we ñ can you open up for questions, Kim
46:45
or, you know?
46:46
Kim Dues: I think, you know, we pretty much have all those answered.
46:50
We have been answering all those questions going along and I think thatís it.
46:54
Holly Cassano: Yeah, we would like to thank everyone for attending.
46:58
Again this was a free webinar, so we have some other things on our website BillingParadise,
47:04
you know that if youíre interested in speaking to us further about risk adjustment, you know
47:11
if youíre having any problems within your practice, within your health plans we have
47:15
you know a team of specialists including Kim and myself that would be happy to assist you
47:20
with any of your needs or any questions, you know if you want to consult with us on something
47:26
on how to better capture, you know or to focus on documentation whatever it happens to be.
47:31
Please feel free to reach out for us, you know, and we would love to hear from you and
47:35
try and help you solve whatever that is, you know happening within your practice or within
47:40
your plan.
47:41
We work with all side by side, you know and again, as I said, I help develop the CRC credential
47:48
and also a National Exam.
47:49
Kim has taken that results and studied diligently and worked with me on many projects including
47:55
many auditing projects, government audits, payer audits, you know numerous.
48:02
And we work with a lot of attorneys you know BillingParadise really has a great workforce
48:07
behind them.
48:08
We do revenue cycle management, healthcare.
48:11
Kim Dues: When you have been in it awhile, that is just kind of what happens.
48:17
Holly Cassano: Absolutely.
48:18
So, again we thank you.
48:20
We hope you enjoyed the presentation and if anyone is interested in obtaining a copy of
48:25
the PowerPoint just reach out to us on BillingParadise.
48:27
Thank you so much and have a wonderful day.
48:30
Kim Dues: Thank you so much.
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