Retrospective Review Pitfalls
A recent blog published by the Gorman Health Group, a consultancy with expertise on government healthcare programs, reviewed the DOJ’s increased focus on risk adjustment compliance. They confirmed that some Medicare Advantage Organizations (MAOs) are struggling to optimize risk adjustment coding while meeting the compliance guidelines set forth by CMS.
If we track the comments and actions by CMS and the DOJ it is clear that coding organic to the patient visit is the preferred method of documenting member disease burden. Industry insiders all know that it’s still the common, if not predominant, practice of MAOs to rely on retrospective chart review as the primary method of discovering conditions that may not have been coded during the patient encounter. They hire staff or outsource retrospective review study to add unreported conditions that were not documented at the point of care. This retrospective review process is expensive and has sometimes resulted in a disconnect between the treating physician and the MAO’s interpretation of the patient’s disease burden. It’s ironic that the treating physician’s coding does not completely document the patient’s disease burden, but we all know that in fact retrospective chart review is an all too frequent occurrence.
When treating physicians incompletely document patient disease burden by under-coding or miscoding patient encounters, an expensive cycle of retrospective review audit is required. Providers are required to transmit records to health plans, or contracted risk adjustment auditors, which increases a medical groups administrative burden. The plan in turn may pay millions of dollars to support an effective retrospective review process and even so, compliance issues abound, such as reporting ailments that have resolved or were incorrectly coded. Since CMS has determined that the health plan is responsible for “the accuracy, completeness, and truthfulness of the submitted data”, poor compliance could result in significant liability issues for those MAOs.
Prospective Review: Always better if the treating physician is involved
Most physicians would love to have risk adjustment coding help if they could afford it. I’ve never met a medical provider that wants to focus on administrative or billing issues concurrent with a patient visit. The challenge is that many treating physicians don’t have the coding manpower to assist them with a prospective risk adjustment review prior to a patient encounter. Even if they have coding staff, those coders are typically overworked and therefore the prospective review, and the benefits of a prospective payment system can easily slip through the cracks.
Some MAOs use prospective review but instead of having the treating doctor participate in the process, they contract with third party vendors who may not be familiar with the patient’s history. Those vendors may report conditions on pre-populated forms supplied by the health plan. In some of these cases there is pressure on the vendor to code disease without support documentation. This is not surprising because the vendor is siloed away from the patient’s host EHR system. Those vendors may rely on healthcare analytics data not verified through medical records and instead only confirmed anecdotally from patient histories and then coded by those vendors.
Everyone’s Risk Adjustment Wish List
The treating provider should code accurately at the point of care
Assist physicians with risk adjustment coding prospectively
Have evidence in the medical record that supports coding decisions
Display evidence that may support a code at the point of care
Limit expensive and burdensome retrospective review
Increase the productivity of prized risk adjustment coding resources
Achieving the Risk Adjustment Wish List
With the advent of NLP technology, applications can utilize artificial intelligence in healthcare to finally make our risk adjustment wish list achievable. Risk adjustment software can now work with the patient’s EHR record real time to improve the accuracy and speed of the prospective review process. Treating physicians can now use clinical decision support built into risk adjustment software to improve compliance with CMS rules. Treating physicians can “get it right the first time” because the right way is actually less hassle.
See how ForeSee Medical’s risk adjustment coding software can help you eliminate retrospective review and capture every appropriate HCC code at the point of care - getting you the reimbursements you deserve.
Blog by: The ForeSee Medical Team