Managed Care - January 2008 - (Page 46) A successful retrospective approach requires highly efCompanies engaged In revenue management fective chart selection algohe HCC payment system has triggered an emergence of outsourcing rithms that identify which needs for plans that lack the internal resources to operate under the charts to review, which parameters of this system. As technology allows for increasingly complex codes should be identified, responses to the steady increase in health care costs, more and more plans and what the yield per chart will find themselves dependent on the help of experts. HCC methodology should be. The goal is to is complex and requires plans to utilize information technology and provide training and supanalytical skills not available internally to all plans. port to physicians, theraCompany Website pists, physician extenders, Dynamic Healthcare Systems www.dynamichealthsys.com and psychologists so that Health Risk Partners www.healthriskpartners.com coding is accurate and comLeprechaun www.lepmed.com plete. MedAssurant www.medassurant.com Because CMS uses curMedicare Advantage Review Associates www.marareviews.com rent risk profiles for future MMC 20/20 www.mmc2020.com payments, plans with up-toPlan Data Management www.plandatamgmt.com date information on file Pophealthman www.pophealthman.com with CMS will be paid more accurately than those submitting post-visit adjustments. While there are winbeneficiaries are homebound or institutionalized dows of opportunity to correct risk profiles, delays and tend to be sicker than average. At the same will affect cash flow. time, clinical coding for these members tends to be Training should be conducted one on one and poorer than average. This combination means that specialty by specialty. Absolute physician buy-in of a comprehensive history and physical exam along this phase is essential for success. Each plan must with good chart documentation for this 6 percent find a practical method of compensating physiof members represents up to 40 percent of the codcians for performing comprehensive assessments ing opportunity, in addition to being the most likely and complete coding. segment in which potential hospitalizations can be “Provider education is key to coding the patients averted with a physician visit.” correctly the first time,” says Dawn Aston, director Experience has also demonstrated that plans of product development at Infocrossing, an inforneed to review charts of specialists (such as cardimation technology company that is working on ologists and oncologists) as well as primary care member eligibility, enrollment, and payment recphysicians. And many plans have found value in onciliation with 300-plus Medicare Advantage orusing nurses as well as certified coders to perform ganizations. “A number of plans are testing out fichart reviews. The clinical training of a nurse not nancial incentive programs for physicians. The one only allows better understanding of the care that is thing we’ve heard that seems to work is health plans being documented in the chart, but can also be going in with their own staff or consultants and critical in identifying opportunities to improve the doing medical chart reviews themselves” and then care of the members (such the need to refer to speputting documentation into the charts to remind cialists). physicians of certain health statuses of members. A critical element of the prospective approach is Signed progress note medical management. Once a plan obtains accurate For an ICD-9 code to be documented, CMS does risk profiles and begins receiving proper payment not require a physician attestation. The code must, from CMS, it is time to invest in medical managehowever, be supported by a signed progress note, ment. Only through aggressive medical manageassociated with an in-person visit, provided by a ment can plans avoid catastrophic events and dequalified provider, seen during a time when the liver better outcomes for the member and better member was in the plan, and coded in strict acfinancial performance for the plan. MC cordance with national coding standards. T 46 MANAGED CARE / JANUARY 2008 http://www.dynamichealthsys.com http://www.healthriskpartners.com http://www.lepmed.com http://www.medassurant.com http://www.marareviews.com http://www.mmc2020.com http://www.plandatamgmt.com http://www.pophealthman.com
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