The Provider's Role in Risk Adjustment Coding

Posted by Continuum on Jun 19, 2018 11:32:00 AM

Physicians must code diagnoses properly to succeed under Medicare & other value-based contracts 

Each year, CMS sets cost benchmarks for every Medicare member, based on the patients’ diagnoses during the prior year. But what if the physician hasn’t reported their patients’ health information accurately or fully? The result is often benchmarks that are set low, and costs of care exceeding benchmarks.

The payer then thinks the provider spent too much on members’ care, and does not recognize or reward the value (high quality/lower cost) of the care provided by the physician. 

That's why proper Medicare risk adjustment coding—entering diagnosis codes in the EMR and on claims and treating for each diagnosis —is essential. Providers who follow best practices for risk adjustment coding have a better chance of earning shared savings. 

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Topics: value-based care, Medicare Advantage, coding, icd-10, risk scoring, risk adjustment, risk adjustment coding

Medicare Advantage Star Rating & the Provider: Rewarding, Complex & Competitive

Posted by Michael Renzi, DO, FACP on May 22, 2018 8:40:27 AM

CMS created the Star Ratings system in 2008 to help seniors compare quality and performance among Medicare Advantage (MA) Part C plans and Part D prescription drug plans (PDPs). Insurance companies also benefit, as a plan’s star rating influences patients and directly affects membership growth. In 2012, CMS upped the ante by linking premiums and bonus payments to each plan’s star rating. Roughly, each half-star change in a plan’s rating affects bonus revenue by 25-30%, with the most significant reductions occurring when a plan drops under 4 stars. In real dollars, a plan increasing their star rating from 3.5 to 4.0 would result in double the annual bonus payment (referred to as a “rebate percentage”). Bonus payments are substantial, with an average amount between $700 - $1,000 per patient per year.

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Topics: CMS, Medicare Advantage, patient experience, payer contracts, quality care

10 Trends Physicians Must Anticipate in 2018

Posted by Continuum on Jan 10, 2018 10:37:14 AM

2018 is expected to be another tumultuous year for the healthcare industry, even though industry growth is projected to remain mostly stable.1 With the repeal of the Affordable Care Act (ACA)’s individual mandate, uncertain policy efforts to strengthen state marketplaces, and ever-increasing insurance premiums, there will be a broad range of challenges facing the industry this year.

Yet for physicians and clinicians, the industry’s shifting tides will not be the center focus. Physicians will place increased emphasis on alleviating operational challenges, improving the quality of care for their patients, and tracking compliance with care plans to improve patient outcomes. These improvements are expected to aid in the decrease of overall healthcare spend, since industry trends in 2018 will focus on innovative ways to lower costs, increase quality, and reduce unnecessary utilization.

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Topics: population health, value-based care, quality care, physicians, Telemedicine, 2018 healthcare trends, quality payment program, care variation, Medicare Advantage, high deductible health plans

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