The Office of Inspector General (OIG) recently updated their Work Plan to include nationwide audits of Medicare Part C high-risk diagnosis codes. OIG Work Plan updates are nothing new, but the OIG’s focus on high-risk diagnosis codes puts even more pressure on medical coders to accurately capture
On April 10th, 2023, the Centers for Medicare & Medicaid Services (CMS) proposed to change the severity of the three ICD-10-CM diagnosis codes connected to homelessness from “non-complication or comorbidity” (NonCC) to “complication or comorbidity” (CC). This proposed change would be a step towards health equity, as
At the end of March 2023, the Centers for Medicare & Medicaid Services (CMS) announced the 2024 Medicare Advantage Rate. The proposed rule introduces major changes to risk adjustment payment policies. Additionally, CMS projects that the plan will lead to a payment increase for Medicare Advantage (MA)
As Medicare Advantage coverage has grown each year, now covering half of all Medicare patients (more than 30 million Americans), fraudulent risk adjustment practices have persisted. The Centers for Medicare & Medicaid Services (CMS) has made several efforts to course correct and avoid unnecessary overpayments. In 2022,
As discussed in a previous article, Medicare Risk Adjustment requires careful collection and validation of patient diagnosis codes before coders can successfully complete their HCC reviews. This work is very important: it is forecasted to drive the alignment of approximately $460 billion in Medicare spending in 2023,
Both the Center for Medicare and Medicaid Services (CMS) and Office of Inspector General (OIG) have voiced concerns regarding risk-adjusted revenue integrity. A recent OIG report found that some Medicare Advantage Organizations (MAOs) may leverage chart reviews and Health Risk Assessments to potentially exaggerate the negative
Medical risk adjustment refers to a process by which healthcare premium funds are allocated to match expected medical costs. Global capitation agreements are provider payment models in which a sponsoring party provides a fixed pro-rata funding allocation on a prospective basis to a service-providing party (such as
The Centers for Medicare and Medicaid services (CMS) implemented the Risk Adjustment Payment System (RAPS) program as a way to determine a Medicare Advantage member’s premium on a prospective basis. The goal is to pay MA and Prescription Drug Plans (PDPs) accurately and fairly by adjusting payment
Establishing rapport early with new members and new patients, whether they joined your panel by choice or automatic assignment, is pivotal. Trust in a physician ranks as the top predictor for whether a patient stays loyal to a physician’s practice. Patients who trust their doctors are more
A risk contract creates a relationship between an insurer and a provider that expands the financial relationship beyond the traditional transactional limits. A risk contract makes a Primary Care Provider (PCP) responsible for all other costs incurred in the care of health plan members assigned or attributed
