MiraMed - Risk Adjustment HCC Coding Primer 2016

Coding
Service
MiraMed
Risk Adjustment
HCC Coding Primer
2016
HCC
Auditing
Clinical
Documentation
Improvement

Healthcare Trends 2016
ICD-10
AccountableCareAct
readmission
penalty
3

Healthcare Trends 2016
ACO
value-based
payment
4

About Medicare
5
In-patient
SNF
Home health
Hospice
Provider services - office visits
Out patient screenings - preventive
Hospital emergency - ambulance
Supplies - durable med-equipment
Medicare
Advantage Plans
Includes Part A & B
Pharmacy benefits
Additional services
Other

What is Risk Adjustment?
A method used to
predict costs and
adjust payment based
on member’s health
status and based on
the relative risk of the
patient’s health status
Hierarchical Condition Category (HCC)

It is used to prospectively adjust payment based
on health status and characteristics of a enrollee
Compares beneficiary to average Medicare beneficiary
What is Risk Adjustment?

What is RAF?
8
Risk Adjustment Factor (RAF)
 RAF is a calculation to predict the cost of care for
beneficiaries
 RA score is determined by using all relative factors of
one patient for a total year
 Demographic and disease information to predict
future healthcare costs
 A higher score represents the sickest patients

Risk Adjusted Model
 Implemented by CMS by the Balanced Budget
Act of 1997
 Model collects information to establish cost of
future patient care
 CMS “risk model” is based on measuring
chronic conditions

Risk Adjustment Types
Medicare Advantage
Commercial plans

 Developed by CMS for risk
adjustment of the Medicare
Advantage Program (Part C)
 CMS has an RX HCC model for risk
adjustment of Medicare Part D
 Medicare - based on age 65 or older
 Current year data predictive of
future year risk
CMS - HCC

 Developed by the Department of
Health and Human Services (HHS)
 Designed for the commercial payer
population
 HHS-HCCs predict the sum of
medical and drug spending
 Includes all ages
HHS - HCC

HCC Program Summary
14
 Medicare Advantage Plans – Part C
 Medicare Shared Savings ACO (expected cost)
 Value-Based Purchasing (expected cost/efficiency)
 Medicaid
 Health Insurance Exchange Plans
 Commercial carriers
 Offers total score for Value Based Purchasing,
population health, risk and cost prediction

Why Do Providers Care?
15
STEP 1 - Physician/hospital must document
clinical information based on HCC code set
Step 1

16
STEP 2 - HHS and CMS uses claims data to
calculate a patient’s risk score for documentation,
coding and billing
Step 2Step 1

17
STEP 3 - CMS pays insurance payer for HCC
accuracy based on providers documentation
and coding
Step 3Step 2Step 1

18
Step 4
Step 3Step 2Step 1
STEP 4 - Payer pays provider based
on correct HCC codes - accuracy
means more revenue for provider

19
 CMS audits to ensure integrity and accuracy of
risk-adjusted payment – compliance risk
 Medicare Advantage plans can be selected for
RADV Audits annually to validate diagnosis
 Providers are required to assist in RADV Audits
RISK ADJUSTMENT
DATA VALIDATION
AUDITS (RADV)

20
HCC reimbursement rates are increasing over the
next three years
There is a financial benefit to the provider and payer
for correctly capturing all HCC codes
There are approximately 10,000 codes that map to
HCCs that need to be understood and captured

Why Do We Care?
21
 HCC is now on the provider’s
radar
 We can audit medical
records to find gaps in HCC
coding
 Reduce provider risk due to
a lack of compliance
 We can assist providers with
clinical documentation and
education

MiraMed HCC Services
22
 Provide retrospective audits
current timeframe or lookback
12 months
 Identify and document missed
HCC codes to increase provider
revenue
 Offer year-end, quarterly or
ad- hoc auditing
 Provide on-site CDI education
and training services

Delivering HCC Services
23
 Use all offshore auditors with a
ramp up timeframe of 60 to 90
days
 Use all onshore auditors
supplied by MMOC
 Use MMOC auditors for quick
ramp up and supplant US
coders with our offshore team

Prospect Contacts
24
Hospital
 CFO
 VP Revenue Cycle
 VP of Managed Care
 Manage Care Executive
 VP of Coding
Physician Group
 Manage Care Executive
 Group Administrator
 ACO Executive Director

Value Proposition
25
 36 year successful revenue cycle
track record
 15 years of coding experience
 Code over 30 million charts
annually – all specialties
 Deliver consistent 95 % accuracy
 Team’s experience: MD, RN,
AHIMA/AAPC Certified - CPC,
CPMA, CPCO, CEDC, CCS, CCS-P,
CIC, CPMA, AHIMA ICD-10-
CM/PCS Trainers

MiraMed - Risk Adjustment HCC Coding Primer 2016

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