GeBBS Healthcare Solutions applies insights to encounter details that lead to appropriate risk scores and ensures compliance.
Patients are complex. This is especially true when they are Medicare Advantage enrollees. These older adults typically enter the health care system with a specific complaint, requesting treatment for that one issue. Their path is not always straightforward. They are diagnosed, treated, and then sent home. Often, some follow-up care happens to monitor the issue and make sure it is not getting worse.
If indeed that were all that was happening, the on-going reimbursement related to that patient would also be simple and straightforward. However, these elderly patients often bring with them a host of other underlying, chronic, and active conditions, too. A weak heart. Breathing problems. Pain in their joints. These chronic conditions can lead to additional complications. This can make it even more complicated for the health plan to ensure that they are receiving the right risk score and not leaving themselves exposed to unnecessary risk when a RADV audit is concerned.
Editor’s Note: Click here to read the full case study that shows how GeBBS’ Payer Solutions can help to comb through data to capture and delete risk-adjusted diagnostic codes to ensure no opportunity is missed.
While some of them may not require treatment in the future (or at least not right away), others will. And if a busy provider doesn’t pay close enough attention to the details when documenting the patient’s specific diagnosis using the correct documentation for HCC codes—or more likely, hasn’t been fully educated about HCC and therefore doesn’t understand the nuances involved in performing this detailed work—the reports they file might not be fully accurate.
Why does that matter? Two important reasons:
- The quality of the care the patient will receive is impacted.
- It puts the financial health of the payer institution behind that enrollee in jeopardy.
And when this happens again and again over time, the results can be catastrophic. In other words, when HCC coding is even slightly “off” it puts everyone—patients, providers, and plans—at high risk.
To see this in action, imagine this: a 79-year-old man who is a Medicare Advantage enrollee goes to his doctor complaining of back pain. He’s overweight. He has diabetes and there’s a place on his foot that’s starting to bother him. He’s also revealed he’s feeling depressed. If he continues this same path, it’s likely he’ll need additional care to treat these other issues as well.
To document the encounter, his busy provider enters diagnosis conditions for that day only but does not go further into documenting the overall care. This simple action—which is repeated in healthcare thousands of times a day—will affect the reimbursement for that patient now, and into the future.
Will this elderly patient get better? Hopefully, the immediate issue will improve, and his doctor will provide the quality care he needs to manage his symptoms. But looking realistically at the whole patient, there’s more than a good chance his chronic conditions, combined with his risk factors—obesity, age, depression and diabetes—are setting him on a path that will require significantly greater, on-going care in the future.
Will the patient get the care he needs, and will the plan be properly reimbursed for this future care they will need to deliver? If risk adjusted conditions are not completely documented and/or abstracted and sent to CMS, the answer could be no.