Managed Care - January 2008 - (Page 43) Lax Coding by Physicians Hurts Medicare Advantage Plans By assisting doctors, insurers can get all the payment that they are due, but that too often is lost dividual health risk profile of each Medicare Advantage member with the premiums paid to the plan bearing the risk. It utilizes ICD-9 information as the primary indicator of each member’s health status. Thousands of ICD-9 codes are mapped to ealth insurers participating in managed specific HCC disease categories, which ultimately Medicare have never experienced as dictate the premiums paid to the Medicare Advanwide a gap between actual and potential tage plan. payment as currently exists. SimIdeally, plans that enroll more complex ply stated, Medicare managed care paypatients will receive higher premiums from ments from the Centers for Medicare & Medicare to provide the necessary services. Medicaid Services depend on accurate and To allow plans an opportunity to prepare, complete diagnostic physician coding. HCC risk payment was phased in over four However, the economics of running a years: 2004 at 30 percent, 2005 at 50 percent, physician practice penalize those who take 2006 at 75 percent and, finally, 2007 at 100 the extra time to code completely. The percent. physician coding that health plans rely on to Proper HCC classification depends on set their premium payment levels is in- Marcia Naveh, MD, both a plan’s ability to obtain accurate dicomplete and inaccurate, and as a result, FACP agnostic information and a plan’s ability to many health plans currently receive drareport that information accurately to CMS. Almatically lower premiums than those to which they though this sounds simple, it has proven to be quite are entitled. That need not be the case, however. challenging from both an operational and clinical perspective. Recent history Obtaining the complete diagnosis data needed In response to the failure of Medicare+Choice, for accurate risk adjustment is fraught with chalthe Medicare Modernization Act of 2003 (MMA) lenges. CMS accepts information regarding a memcreated Medicare Advantage, which relies on the ber’s health status from limited sources, one major hierarchical condition category (HCC) system to one being medical charts from physician offices. formulate payments for participating managed care Unfortunately, physicians are not trained or moplans. HCC payment is designed to match the intivated to document the complete spectrum of applicable diagnosis codes during an office visit, as only one valid diagnosis code is required for the Marcia Naveh, MD, FACP, is the chief medical physician to receive compensation. officer of Matrix Medical Network. She received BS The health plan, however, must obtain every exand MS degrees from Tulane University and an isting diagnosis coded in order to obtain an apMD from Albert Einstein College of Medicine in propriate risk score and receive proper payment New York. Naveh is an assistant professor of clinical from CMS. Failure to do so can cost plans millions medicine at the College of Physicians and Surgeons of dollars per year that could be used to provide at Columbia University in New York. Matrix manneeded medical services to members. ages high-risk members for health plans throughout Consider: A patient has a cold but has suffered a the country. It operates in 14 states. The author can previous stroke, is diabetic and has Parkinson’s disbe reached at MNaveh@MatrixHealth.net. By Marcia Naveh, MD Chief Medical Officer Matrix Medical Network H JANUARY 2008 / MANAGED CARE 43
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