January 31, 2017
As we are well into the new year, health systems, providers, and payers should assess their current risk adjustment process and plan to make improvements starting with documentation and coding, understanding CMS deadlines and rule updates, and analyzing final reports.
Here are 5 tips to better manage and improve the risk adjustment process:
1. BE ON TRACK WITH CMS DEADLINES
Centers for Medicare & Medicaid Services (CMS) provides advance notice to inform health systems and health plans on what to do and when to prepare for risk adjustment updates. Understanding the latest updates in advance and developing a strategy early will position your organization for appropriate funding and reimbursement. Be on the lookout for deadlines approaching in March for your Medicare Advantage population and April for your Affordable Care Act population.
2. DOCUMENTATION AND CODING
Accurately capturing all diagnosis and Hierarchical Condition Category (HCC) codes when coding is important. The slightest variation in coding accuracy can greatly impact revenue and create a higher risk of getting audited. Consider education or training with your team or outsource to a vendor who specializes in coding and risk adjustment.
3. MULTIPLE REVIEW STRATEGY
Double-check your data! Conducting multiple quality assurance reviews and audits throughout the process will ensure you are receiving the highest level of accuracy and validation prior to submission to CMS. Consider conducting reviews on a quarterly basis to allow your HCCs to be submitted and accepted by CMS prior to payment, and reduce costs with several reviews on a weekly or monthly basis.
4. MONITOR METRICS
Know and understand your population to better identify members/patients with the highest probability of having undocumented conditions.
5. ANALYZE DATA
Each year is a new opportunity to recover revenue that was left on the table one year prior.