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Improving Medicare Risk Adjustment - A RISE Retrospective

Posted by Mark Moticik on Thu, Apr 21, 2016

With the RISE Nashville Summit shrinking in the rearview mirror but still fresh in our collective memories it’s time to act on what we learned from our peers and expert presenters.  In the spirit of full disclosure, this was my first time attending RISE Nashville so my experience is likely much different than a veteran event goer.  My AHA! moment came sometime toward the end of the second day when I found time to peruse the exhibit floor.  I was struck by how relatively few exhibitors offer enterprise level technology specifically focused on risk adjustment.  Now, many will rightly point out the bevy of data analytics companies, so let me explain. 

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Tags: risk adjustment

Prepare for 100% Overread - Medical Record Review Validation

Posted by Michael Curran on Mon, Feb 22, 2016


For many years the Medical Record Review Validation audit followed a relatively straight forward, tried and true process. At the beginning of the season, plans learned what measures would be selected for review knowing that new ones would be added only if the compliance auditor thought there was a potential issue across the core group. Plans would review a specified number of charts within the core measure groups at about the half-way point of the retrieval process.  If problems were detected with the way a measure was being abstracted, the plan had time to take corrective action and get re-assessed.  Otherwise, if everything looked good, the measure passed and the charts would be filed away, never to be seen again.  That’s an overly simplistic but you get the point.  

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Tags: medical record review validation, medical record abstraction, medical record review, MRRV audit, MRRV, MRRV wizard, NCQA, HEDIS, NCQA HEDIS, audit, overread, audit prep

The Twelve Days of the Final MA Sweep – With a Bit of an Eggnog Twist

Posted by Donna Kober on Wed, Dec 23, 2015

 

A tongue-in-cheek take on our collective Risk Adjustment Dysfunctions

So we’re only a few days away. And I am not talking about Christmas! I am talking about the end of the year rush to get all of the 2014 DOS submitted to CMS before the big door is closed. Each year around this time, many payers and their providers go into a craze to get all the reviews completed in time for submission.

Now that I think about it, Christmas is a good analogy to the CMS final sweeps. Each year, children count the days until the big man comes and leave presents under the tree and then they don’t have to behave for another 360 days. Each year, providers and insurance companies count the days until their coders and/or vendors provide that final RAPS submission to CMS and then they can relax for another few months.

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Tags: CMS, risk adjustment, RAPS, DOS, MA Sweeps

Security, PHI, and Bad Coffee

Posted by Michael Klotz on Thu, Nov 12, 2015

Information security and protecting PHI is top of mind for all of us in Healthcare IT. So, of course we follow best practices, coding guidelines, implement security features, and have all the policies, procedures, and training for users. Every year, we also go through an extensive audit and penetration testing exercise performed by an independent security audit firm.
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Tags: healthcare IT, Security, MRCS Platform, software platform, audit, Coding, coffee, PHI

How to Address Coders' Forever Changing Job Descriptions

Posted by Donna Kober on Mon, Oct 19, 2015


In our last blog, our discussion revolved around the ambiguous nature of coders’ job descriptions. Today I want to discuss how we can restore some order and eliminate a lot of the ambiguity and uncertainty.

Today’s coders and coding teams must be flexible and ever so conscious in the difference in coding expectations of various organizations. But beyond that, how do teams of coders consistently adhere to the expectations? How does the consumer of the coded information know that their expectations have been met and how to use the information accordingly?

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Tags: CMS, RADV, Coding, HCC, MEAT, vendor, VRC, RxHCC, DOS

The Certified Coders’ Ambiguous Job Description

Posted by Donna Kober on Tue, Sep 22, 2015

Certified coders’ job descriptions have once again been redefined due to CMS, OIG, their respective audits, and many other factors over time. We are now the gatekeeper of diagnoses, document translators, and finally coders.  I am not sure how we managed to obtain all this power, and I am not even sure we should have it!  Coders are trained to review documentation and abstract the correct diagnoses and procedures…code what the clinician documents.

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Tags: medical record abstraction, CMS, ICD-10, healthcare coders, audit, Coding, PMH, encounter, OIG

Ways to Improve your HEDIS® 2016 Scores Now

Posted by Michael Curran on Mon, Aug 31, 2015


With HEDIS® 2015 well behind us, now is the time to start planning for HEDIS® 2016. While the active medical record collection period is short, HEDIS® is a year-round activity and there are many opportunities to make next year results even better. It boils down to data gaps and identifying where those gaps exist. With that in mind, you can identify interventions for your health plans, providers, and members. Taking action to close these gaps can drastically improve your HEDIS® and STAR Ratings for the following year.  

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Tags: STAR ratings, CMS 5 Star Rating, HEDIS audit, provider data, provider relations, HEDIS, NCQA HEDIS, provider abrasion, gap closure, EMR, HEDIS 2015, gaps, supplemental data, provider engagement, HEDIS 2016

Leverage Risk Adjustment Charts for Medicare HEDIS® Gains in the Off–Season

Posted by Michael Curran on Thu, Aug 13, 2015

Just because the HEDIS® reporting season has ended, doesn’t mean that there is not still valuable chart review to be done. Those charts that hold value for HEDIS® scores and Stars rating could be coming into your organization right now.

Risk Adjustment chart collection occurs virtually year-round and there is a very good chance that your plan is acquiring charts right now for that purpose. Although there are clearly limits to how you can use partial year chart data for HEDIS® reporting, mining these charts in the HEDIS® off-season can yield potential outreach opportunities and possible valid exclusions for low denominator, administrative-only HEDIS® measures.

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Tags: quality improvement, STAR ratings, HEDIS quality improvement, CMS 5 Star Rating, chart review, medical records, HEDIS measures, STAR rating, Medicare Advantage, HEDIS, off season

HHS Skips RADV in 2015 – Should Exchange Plans Do Mock RADV Audits?

Posted by Bryan Lee on Thu, Aug 06, 2015

With CMS’ recent announcement of the delayed implementation of HHS Risk Adjustment Data Validation (HRADV), a number of colleagues involved in risk adjustment for commercial exchange plans have been wondering if they should still be conducting mock RADV audits; or do something else; or do nothing for now.   While I have never been an advocate for conducting ‘MOCK’ RADV audits in a manner that exposes a health plan to greater financial risk, I do strongly encourage everyone I talk with to conduct periodic RADV Preparedness ‘Fire Drills’ and Targeted Audits. Those plans that just got a reprieve from the HHS RADV are no exception.

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Tags: CMS, risk adjustment, health exchange, HIX, RADV, commercial plans, HCC, IVA, Mock RADV, HHS, HRADV

Carnegie, Bridges, and Our Antiquated Medical Records Review Processes

Posted by Michael Klotz on Thu, Jul 30, 2015

I recently watched a documentary series called ‘The Men Who Built America’ on Netflix. One of these men, Andrew Carnegie, is usually known as a Pittsburgh steel magnate, one of the richest people in history, and his philanthropic legacy including Carnegie Hall. Less well known, perhaps, is the fact that he started out in the railroad business.

So what does any of this, you may ask, have to do with how we perform Medical Records Reviews today? Bear with me…

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Tags: SaaS, medical record review, MRRV, MRCS Platform, software platform, medical records retrieval, MRR, medical record analysis, workflow, Coding, vendor

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