RaeAnn Grossman.

Solving your claims-based HCC conundrum

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Everybody knows that 37% of claims-based HCCs fail in a RADV audit, but no one ever talks about how to fix the problem.

How to fix the high failure rate of claims based HCCs?

1. Filter your claims and tier into confidence levels (high, moderate and low). (We call our filtration, tiering, and resolution tracking solution CareCurrent.) We recommend you filter on frequency, site of service, provider of service, clinical significance, plus CMS compliance and clinical condition alignment.
2. Audit your medical groups with both the highest member density plus your providers consistently in your low confidence coding tier.
3. Note the diagnoses or most common conditions inaccurately recorded.
4. Meet with physicians and staff to create an evaluation to billing process improvement workflow for your top three most common inaccurate codes. Repeat this education and communication with other medical groups.
5. Re-stratify your claims and note improvements using CareCurrent if you have no internal system.
6. Audit the new dates of service stratified and glean if the education and new workflow aided in more specificity or accuracy in coding.
7. Create clinical and coding initiatives as appropriate to compliment your coding areas of improvement.

If you note that previous codes were inaccurately billed in claims and submitted to CMS, delete the codes prior to final sweeps to ensure appropriate payment and audit success.

RaeAnn Grossman.

About RaeAnn Grossman.

RaeAnn Grossman is one of the nation’s foremost experts on risk adjustment strategies and provider and payer alliance configurations, along with healthcare business and product development. She brings Gorman Health Group more than twenty years of professional experience in a wide variety of healthcare organizations including Health Plans, Medical Groups, Physician Hospital Organizations (PHOs), Integrated Hospital Systems, and Institute of Health Professionals Education. Read more

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