Missing any of the HCC codes to CMS can lead to underpayments while incorrect diagnosis codes can lead to overpayments affecting the entire healthcare system as a whole.
If you are a healthcare Payer performing risk adjustment factor (RAF) derivations and Audits, In that case, I’m sure you will understand the importance of identifying and validating accurate Hierarchical Condition Category (HCC) diagnosis codes for the Centers for Medicare & Medicaid Services (CMS) submissions.
With the Medicare Advantage program offering beneficiaries to enroll in private health care plans, CMS contracts with those MA organizations, which in turn, contracts with health care providers and physicians too.
Role of CMS in the risk adjustment program
CMS consolidates certain HCCs into related-disease groups, and with each of these groups, it assigns an HCC for the most severe diagnosis code.
Therefore, it is important for an MA organization to ensure appropriate identification and validations of HCC codes to CMS, as it will use the most severe ones in determining the final RAF scores for an enrollee.
What does a Retrospective Audit mean for an MA organization?
- Ensure quality care is being provided to Medicare beneficiaries
- Adhering to the Federal guidelines
- Enhance revenue cycle management
- Optimize reimbursements
- Defend against federal and payers audits, health plan denials, and malpractice litigations.
How Retrospective Audit is helping MA organizations mitigate risk for the final submission of RAF scores to CMS?
Retrospective review and audit protect MA organizations from CMS penalties by performing first-level review and second-level review to validate the medical coder’s findings for mapping the final HCC summary and RAF score calculation.
What are the types of Audits?
- RADV (Risk Adjustment Data Validation) Audit
- OIG (Office of Inspector General) Audit
- IVA (Independent Validation Audit) Audit
RAAPID’s Retrospective Audit Workflow for health plans and audit organizations
- Identify chronic conditions along with evidence and map them to HCC codes
- Find ICD-10-CM codes
- Recognize substantiated HCCs, unsubstantiated HCCs, unreported HCCs, net-new HCCs
- Calculate RAF scores based on demographics and HCCs.
Key benefits of using RAAPID’s AI-based Audit Solution
- Uncovering diagnosis and conditions missing from original claims
- Optimizing risk-adjusted revenue
- Capturing chronicity levels secondary manifestations based on evidence
- Mitigating RADV audit risk with unsubstantiated HCCs, substantiated HCCs, and unreported HCCs
- Ensuring optimal, accurate, and compliant CMS claim submissions.
To sum up
RAPPID, the nextgen AI-based, NLP-powered risk adjustment retrospective audit solution is helpful to coding and auditing vendors for health plan organizations, auditing vendors for CMS/OIG/IVA, health plan providers, healthcare IT companies, integrated delivery networks, Managed Care Organizations (MCO), Accountable Care Organizations (ACO), Independent Practice Associations (IPA), At-risk Providers (participating in value-based-care), Provider-sponsored Health Plans, Self-insured employers and home care providers (participating in value-based-care).
The modern risk adjustment medical coding solution is available as Saas and API!