Risk adjustment for ACOS

Accountable Care Act (ACA) has changed the landscape for all parties involved - from Insurers to Providers to Patients themselves. Even though the current administration is not fully supportive of the act, it'll be nearly impossible to roll back ACA insurance from the marketplace as it has penetrated deeply into the American economy.

CMS has continued to push value-based reimbursement and hence the tide of change is drifting towards improvement in the quality of care risk-sharing between providers and payers.

Risk Adjustment Coding Tips to Improve Clinical Documentation:

• Identify patient name, date of service, and date of birth on each page of the record

• Reported diagnoses must be supported with medical record documentation

• CMS requires that the documentation show evaluation, monitoring, or treatment of the conditions documented

• All dates of service must be signed and dated by the provider, stamps are not acceptable. 'History of' means that the patient no longer has the condition and cannot be coded as an active disease.

accountable care organizations (ACo's)

In January 2016, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (Innovation Center) launched an accountable care organization (ACO) model called the Next Generation ACO Model. Eighteen ACOs participated in the Next Generation ACO Model for the 2016 performance year 45 participated in the 2017 performance year, and 51 are participating in the 2018 performance year. The 51 total ACOs participating in the Next Generation ACO Model in 2018 have significant experience coordinating care for populations of patients through initiatives, including, but not limited to, the Medicare Shared Savings Program and the Pioneer ACO Model. The Next Generation ACO Model is an Advanced Alternative Payment Model (APM) under the Quality Payment Program established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Eligible clinicians that sufficiently participate in Advanced APMs may qualify for exemption from payment adjustments under the Merit-based Incentive Payment System (MIPS), as well as APM incentive payments available beginning in 2019. Contact Us today for free consultation on how you can join the program.

Incorporating risk adjustment into the provider payment risk-sharing arrangement is becoming an industry standard. With the push for increased care quality and collaboration between insurers and provider groups on the rise, alternatives to the traditional fee-for-service reimbursement are inevitable. While fee-for-service arrangements are simple and comfortable, alternative arrangements like bundling, capitation, and risk-sharing allow for a much higher level of customization and intricacy in contracting.

Without risk adjustment, providers in disproportionately higher-risk populated areas would receive payment reductions that may not reflect accurately the quality of care they provide. Risk adjustment allows for more accurate comparisons across provider Tax Identification Numbers by removing differences in health and other risk factors that affect measured outcomes not under the provider's control.

Whether risk adjustment is used for Medicaid, Medicare, or commercial health plans, the methodologies all use ICD-10 diagnosis codes to define the health conditions of each member during a plan year. Providers document the diagnosis codes on claims submitted to the health plan, and the completeness and specificity of the codes is a critical factor in determining the risk score. A member with multiple chronic conditions will have a higher risk score than a member with no conditions, and that risk score is a key factor in determining reimbursement for Medicare Advantage plans and end-of-year financial adjustments for ACA plans.

Accurate risk categorization identifies members for disease management interventions and assists in the financial forecasting of future medical needs. Improved documentation and coding lead to better patient care, as they are the primary means of communicating the patient record for specialty care to health plans and CMS.

Health Data Max LLC proprietary cloud-based solution analyzes your member and provider claims that provide advanced analytics and predicts conditions using machine-learning models. Best of all, it's all on the cloud so you can access these reports from anywhere on any device.