The first 90 days of implementing a risk adjustment program are critical to laying the foundation for long-term success. Whether your goal is optimizing HCC (Hierarchical Condition Category) coding, improving clinical documentation, or ensuring compliance, tracking the right Key Performance Indicators (KPIs) during this period is esse... Read more

A successful risk adjustment program doesn’t happen by chance—it requires a structured, strategic approach. The first 30 days are critical for establishing a strong foundation, aligning key stakeholders, and setting the stage for long-term success.

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If you’re reading this, you’re likely aware that accurate HCC coding is critical within value-based care (VBC) models. Yet, clinicians often face challenges with complex workflows that make documentation difficult.

When considering a patient’s chart, every detail matters. It’s not just about the diagnosis, it’s the whole picture – missing something could affect the quality of care your patient receives. By now, it’s clear to most HCPs that Read more

Introduction

Research compliance in the CMS risk-adjustment model and you might come away with more questions than answers. There are few rigid guidelines or ... Read more

When we talk about optimizing health system performance in the value-based care (VBC) model, it’s common to refer to the Read more

Clinicians and other medical staff find it hard to care about HCC coding. Here’s why they should.

Selling clinicians on the value-based care (VBC) model should be straightforward. In theory, it promises more time with patien... Read more

We asked VBC thought leaders to share their experiences of fee-for-service and value-based reimbursement models. 

While value-based payment models are on the rise in the U.S, primary care practices still receive the majority of their pay... Read more

Healthcare is a dynamic and complex industry, constantly evolving to provide the best possible care to patients. In this ever-changing landscape, accurate Hierarchical Condition Category (HCC) coding and risk adjustment<... Read more

The CMS, or Centers for Medicare & Medicaid Services, developed the HCC Risk Adjustment Model to determine Medicare Advantage (MA) plan payments, based on the expected healthcare costs of plan enrolees. HCC stands for Hierarchic... Read more

'HCC coding' is shorthand for the Hierarchical Condition Category (HCC) coding system used to identify and classify medical conditions for the purpose of risk adjustment. ThisRead more

Healthcare providers and payers use the HCC coding system to identify the seriousness and severity of a patient’s medical condition. The main purpose of coding is to ensure that a patient receives good medical... Read more

Medicare risk adjustment factor score accuracy is an important measure of the quality of care provided by healthcare providers. By understanding and applying proven strategies to improve RAF score accuracy, healthcare organizations can demonstrate their commitment to quality care and improve overall patient outcomes. In this article, ... Read more

HCC (Hierarchical condition category) coding is a complex and ever-changing field, and training clinicians in the traditional seminar format can cause significant pain points for healthcare providers and administrators. Here are just a few examples of the pain points that result from HCC coding education seminars:   Inaccurate or incomplete information: Traditional seminars often... Read more

The basics of RAF and how it is calculated.

A CMS Medicare Advantage audit is a process used by the Centers for Medicare and Medicaid Services (CMS) to ensure that Medicare Advantage (MA) plans, also known as Medicare Part C, are complying with regulations and standards set by the CMS. The process includes several stages, including notification of the audit, preparation, on-site review, audit findings, and potential repayment or appeals. ... Read more

As a healthcare provider, it's essential to understand the importance of accurate HCC (Hierarchical Condition Category) coding. HCC codes are used to classify patient conditions, which determines  Medicare Advantage payments. Inaccurate HCC coding can have serious consequences for both your practice and your patients.   Inaccurate HCC Coding Impac... Read more

Diagnosing for risk in VBC is the unsung hero fixing healthcare behind the scenes. In this blog, we dig into diagnosing for medical complexity & documenting with ICD-10 codes.   

Diagnosing for medical complexity

Here is the cheat sheet you’re looking for: DOWNLOAD    ICD-10 codes are hard. Knowing which codes to use for Risk Adjustment in your Value-Based Care is even harder. And even the best available clinician training rarely yields lasting... Read more

As a healthcare provider, you know the importance of accurately and consistently documenting diagnoses, but not just to align revenue - there is a far greater reason for specific, accurate HCC coding: patient care. One thing that is often overlooked when calculating RAF scores is the simple fact that Risk Adjustment Factor is the simplest way to track a patient’s ... Read more

The relationship between medical complexity, documentation, risk, innovation, and revenue is actually far more simple than it sounds.

We get it, HCC coding is hard: choosing the right HCC is nuanced, and can seem subjective. But when you see a patient, you are probably not reaching for a cheat sheet on how to diagnose this patient, right? How is it that HCC coding sent you searching for a cheat sheet? &n... Read more

Values-based healthcare reimbursement has been adopted more quickly in some healthcare sectors than in others.   According to the LAN's latest APM Measurement report, 40.9% of US healthcare payments—representing over 238 million Americans and more than 80% of the covered population—were generated through value-ba... Read more

Fred Schulte, Kaiser Health News and Holly Hacker Republished with permission

With the flu season ramping at unprecedented rates, and a new surge of RSV coming when COVID-19 numbers are rising again, the topic of a healthcare surge emergency is back in the headlines. What the New York Times is calling a “Tripledemic” is threatening to overwhelm providers and hospitals yet again. During the peak of the pandemic, hospitals experienced a sur... Read more

Audits are no longer just for large payors, provider groups are feeling the pressure of rising compliance audits, and the playing field is complicated to negotiate. Some of this may seem unfair, but with the cost of medical fraud on the rise, the DOJ, CMS, OIG, HMS and all the other initials are not going to let up any time soon, if ever.   Read more

Back in 2004, CMS introduced HCC coding as a tool to help estimate Medicare costs. Today, HCC coding us used across Medicare Advantage plans, the Medicare Shared Savings Program, Medicaid, and private health plans - all deploying a variation of the risk adjustment model in order to quantify the upcoming cost of care for their member population, and as a mechanism of... Read more

DOJ Audits And How DoctusTech Helps

Nearly 60 percent of health systems are looking to move into risk-based Medicare Advantage programmes in the coming year, according to the Healthcare Financial Management Association (HFMA) executive survey for Guidehouse Health Insights. This is a 14 percent increase from the June 2019 Guidehouse/HFMA analysis, Guidehouse said.   Read more

According to the American Journal of Managed Care (AJMC), the least effective method for continuing medical education (CME) for clinicians is distributing printed materials: emails, PDFs, flyers, email blasts, and so on. Many medical professionals believe that clinician education should be concerned with encouraging continuous development rather than simply raising ... Read more

Value-Based Care is a natural movement toward the benefit of the patient with a reduction in costs by aligning all incentives in the right direction. And as providers make the shift, patients will be encouraged both by the motive behind the transition as well as the improvement in their overall health and the reduction in the costs of their care. Truly, Value-Based ... Read more

In an effort to strengthen its presence in the healthcare technology sector, CVS Health has announced plans to acquire Signify Health for $8 billion. CVS will be acquiring Signify from private equity firm TPG and other Signify shareholders. As a result of this acquisition, CVS will now have access to Signify’s enterprise-grade software solutions for clinical asses... Read more

In December of 2021, the Mayo Clinic published an alarming report: ⅓ of physicians surveyed intended to reduce their work hours - that represents 336,000 doctors. While—and I hope you are sitting down—1 in 5 physicians intended to leave their practice altogether - 20%, or 204,000. The cause? Burnout. Burnout from workload, COVID-19–related anxiety/depression, and fear of contracting ... Read more

HCC coding accurately estimates future healthcare costs while improving patient care. But like any other tool, it’s only effective if the people who use it mas... Read more

DOJ jumps into yet another False Claims Act lawsuit, this time regarding the Cigna Medicare Advantage Fraud Case. The Department of Justice has joined a False Claims Act lawsuit against Cigna Corp. that alleges the health insurance provider exaggerated the illnesses of its Medicare members in order to receive higher payouts from the federal government.  &... Read more

“I don’t care if the RAF goes up or down, I only care if it’s accurate.” Dr. Farshid Kazi, Co-Founder, DoctusTech   If an organization is caught over-coding, up-coing, diagnosing conditions that either do not exist or are not supported in the chart, the cost of these ... Read more

Amazon has announced plans to buy OneMedical for $3B. OneMedical is a brick and mortar plus digital healthcare marketplace that operates in several major U.S. markets. The acquisition is Amazon’s latest move in the healthcare sector, and analysts say it could be a sign of bigger things to come. This is not Amazon’s first foray into the healthcare market, but aft... Read more

DoctusTech helps clinicians learn HCC coding through clinical vignettes in an app that is fun and engaging. Diagnosing with the appropriate HCC code is a critical skill for modern clinicians who care for patients in a value-based care arrangement. You cannot treat what you do not accurately diagnose, and you cannot afford to treat what you do not appropriately code.... Read more

Why is HCC coding training important? Without proper coding, it is impossible to diagnose accurately, treat effectively, document those diagnoses, or achieve revenue goals. Coding training will help you master the skills you need to properly code patient records, so investing in HCC coding training might be the right move for you! Read on to learn more about HCC cod... Read more

Risk adjustment coding is a vital part of any managed care organization. It helps to ensure that patients are appropriately diagnosed and documented accurately according to risk level, which in turn allows the organization to receive appropriate capitated payments to provide all the care needed to reduce avoidable hospitalizations and achieve maximum health. And reg... Read more

Value-Based Care is a game-changing advancements for patients and the providers who care for them. Value-based care is revolutionizing  the healthcare industry and aligning incentives more and more each year. The concept of pay-for-performance, patient-centered care, and outcome measures have all been developed with the intention of providing more value to patients... Read more

HCC Coding And RAF are vital to modern healthcare, and we've recently received some incredible client data we'd very much like to share. And we all know the perils of sharing a win that deals with customer data, which is in turn patient data. And by “perils,” what we really mean is impossibility. Sometimes, the news is so good that it’s impossible not to share... Read more

HCC coding education is a fast growing need for physicians. To meet the demands of today’s fast-paced and dynamic healthcare environment, many are now accelerating their transformation from a hospital-centered fee-for-service model to a more patient-centered model, and Value-Based Care is at the forefront of this change. The increased HCC coding knowledge requires... Read more

The Office of Inspector General is cracking down on Medicare Advantage  prior authorizations that were denied which would have been approved under fee-for-service Medicare rules. Excerpts from the OIG Medicare Advantage prior authorizations denial report follow, quoted in full, arranged for clarity, and followed by our comments.   Read more

Revenue cycle management (RCM) is a hot topic this year. Monitoring, analyzing and improving the efficiency of your organization’s revenue processes is top of mind for leaders across many healthcare organizations. And you’ are probably still reading because you know that improving your organization’s revenue processes is essential to its success. But are you d... Read more

As the U.S healthcare system transitions towards value-based payment models, independent clinicians and physician groups continue to face HCC coding challenges that not only impact their bottom-line, but patient care as well. On top of all this, the pandemic has added a significant burden to the already stretched clinician workload.   Here are 4 key HCC coding challenges clinicians are ... Read more

In a move that surprised very few in healthcare—and fewer on Capitol Hill—SCOTUS refused to hear UnitedHealth’s case against the 2014 Medicare Advantage Overpayment Rule. In the case of UNITEDHEALTHCARE CO., ET AL. V. BECERRA, SEC. OF H&HS, ET AL. the lower court’s ruling stands.  

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RaDonda Vaught was just sentenced to three years of supervised probation. The former Vanderbilt University Medical Center nurse was found guilty of negligent homicide and gross neglect of an impaired adult in the death of a patient, because she administered Read more

Implementing Value-Based Care is essential for today's physician. Value-based care is a system of payment and reimbursement that rewards healthcare providers for delivering high-quality, cost-effective care to patients. There are two ways to improve the value of care: improving the quality of care (fewer complications, less re-hospitalization, shorter length of stay... Read more

Looking for a quick HCC coding knowledge hack?  Use this Quick Guide to identify HCC codes for risk adjustment. Diagnosis coding for value-based payment models is one of the key drivers for innovation in modern healthcare - aligning incentives with care in ways that were only talked about in decades past. However, without appropriate and deep HCC coding knowledge, ... Read more

It has long been thought that the machinery of the US healthcare system is so big, so complex and so established that steering the ship is nearly impossible. However, if we’ve learned anything from the COVID-19 pandemic, we can be nimble when we have to be. Lives were on the line, the nation itself was at stake, and The Indu... Read more

The US healthcare market is leaning in the direction of Full Risk Value-Based Care. While the system is often characterized as a monolith; a massive, unwieldy machine (and as immovable objects go, it is a big one),  that big machine is trending steadily toward full risk value-based care.   The CMS recently reported ... Read more

As we look forward to the release of ACPLAN’s 2022 Alternative Payment Method report, let’s review data from their previous six annual reports. One clear takeaway is that Value-Based Care payments increasing year over year is a trend that shows no signs of stopping. Trend lines point to the inevitable rise of Full Risk, but slowly - as most of the year-over-year... Read more

Notes and insights from a study published by AJMC on how to change physician behavior. "The authors evaluated methods for implementing clinical research and guidelines, in order to change physician practice patterns, in surgical and general practice. They evaluated the effectiveness of different implementation methods."   And as we have demonstrated through successful behavior change in... Read more

Medicare Advantage Compliance Audits: The Department of Health and Human Services Office of Inspector General regularly audits Medicare Advantage contracts and reports out specific diagnosis codes deemed improper. They also report the estimated overpayments associated with the specific diagnosis codes, and recommend repayments.  Below, you'll find all of the specif... Read more

Excerpts, notes and quotes from the DOJ 2021 Fiscal Year Report

Specificity and accuracy are the keys to any successful Value-Based Care program. And clinical vignettes are a great way to learn.   Five years ago, the AAFP (American Academy of Family Physicians) published a crash course to educate family physicians on HCC coding. To this day, the clinical vignettes from this family physician HCC coding education course... Read more

Requiring clinicians to learn one more thing—especially when HCC coding does not feel connected to treating patients—is a big ask. Expecting them to learn in ways that are both ineffective and profoundly dull is just plain cruel.   Read more

Excerpts from a study.   Humana’s Chief Medical Officer, William Shrank, MD, MSHS, co-wrote a study in March (published by JAMA)  titled “Analysis of Value-Based Payment and Acute Care Use Among Medicare Advantage Beneficiar... Read more

A guest walks into an upscale hotel and unburdens himself of several suitcases into the waiting hands of an eager bellhop. When both arrive at the room, rather than giving a tip, the guest offers a hearty thanks! With a dry smile, the bellhop frankly states, “‘Thank you’ don?... Read more

In Friday’s “State of the Department” address, HHS Secretary Xavier Becerra spoke candidly about upcoding and overcharging in Medicare Advantage. After offering prepared remarks on the continuing COVID public health emergency, Robert King of Fierce Healthcare asked very pointedly about upcoding in Medicare Advantage. Secr... Read more

We recently ran a poll asking how doctors preferred to learn about HCC documentation training tools and resources, and 50% selected “Peer Recommendations.” Fortunately, doctors just like you are using and loving our platform, and eager to share their experiences. We’ve broken their testimonials into three categories:  Ease of use, Depth of learning, Accuracy,... Read more

CMS recently unveiled their replacement for the Direct Contracting Model (DCE), renamed now as the ACO REACH Model. Many of the original Direct Contracting Model tenets will remain the same, with a few significant changes announced.   From heightened scrutiny on up-coding and do... Read more

  Levi Wiggins: Alright. Here we are. Live with Dr. Kazi for Year End Preparation for 2022: things to stop doing, things to start doing and things to keep doing. Our host, as always, is Dr. Kazi. Give us a brief introduction!   Farshid Kazi, MD: Thank you everybody. Farshid Kazi, internist by tr... Read more

CMS released its final Medicare Shared Savings Program rule, called “Pathways for Success” for ACOs. The new rule is designed to help establish a path toward risk, with a heavy focus on Risk Adjustment Coding. CMS = Centers for Medicare & Medicaid Services || Read more