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- Janet on What Sequestration Could Mean to Medicare Advantage Claims Payment
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- Jane Wall Medicare Health Benefits Inc on Strange Bedfellows Come to Medicare Advantage’s Rescue
Tag Archives: HCC Management
Everybody knows that 37% of claims-based HCCs fail in a RADV audit, but no one ever talks about how to fix the problem.
Many of our clients have requested customized mapping and integration which electronically links the findings from the Advanced Evaluation into their medical management system. Health plans and medical groups both appreciate the in-depth reporting, plus electronic connection that triggers or flags particular members for placement into unique case management programs, whether it is a COPD, CHF, frail and fall reduction, or chronic kidney disease referral.
Health plans have tried a hundred ways to engage providers – incentive stipends, P4P, P4Q, capitation, clinical initiatives, episode of care payment, onsite coders, in office case management liaisons. But what works? Open communication, reasonable expectations, and simplicity.
So you may have bad, ugly, horrible, scary data and internally you don’t have a means to lump it all together to give you a clear picture of what happened in 2010, 2011, and the challenges you are facing in 2012 with your members, your network physicians or your risk adjustment program.
You hear a lot of interesting comments when you are meeting with health plans and large medical groups. One of my favorite phrases is “last year was a goat rodeo.” The visual makes me laugh every time – goats, kids, and general goat chaos. However, in risk adjustment, you cannot afford an internal or vendor “goat rodeo.”
There have been recent suggestions that Medicare Advantage plans are receiving excessive reimbursement from CMS as a result of “up coding” in the risk adjustment system. There are a number of reasons why these suggestions are inaccurate and counterproductive.