HCC/Risk Adjustment Services

Expert consulting with over a decade of experience in HCC Coding and Risk Adjustment Reviews.

RMC offers expert consulting in HCC coding and risk adjustment. Any organization (health plans, physician groups, and other health systems), who is impacted by risk adjustment models or reimbursement, should perform audits and/or reviews to ensure appropriate reimbursement and overall compliance. We have over a decade of experience in risk adjustment arena and have performed audits for health plans, physician groups, individual clinics, etc.

WHAT IS A RISK ADJUSTMENT AUDIT?

In an RMC HCC/RA coding audit, patient charts are reviewed for accuracy of documentation, validating already reported HCCs, locating “missed” HCCs, or suggesting deletions. These reviews can be done by encounter, by provider, or the whole patient profile for a specified period of time.

An audit can be performed either remote access to an entity’s electronic records system or having copies of the charts provided for review. RMC works with our clients to delineate what patients are reviewed and delineate what the objectives are for the proposed review.

Additionally, reviews are in accordance with national coding guidelines and in accordance with payor regulations.

 

WHY IS THERE A NEED FOR RISK ADJUSTMENT AUDITS?

There are many reasons to have the risk adjustment audits performed. First would be for compliance purposes. Compliant documentation and coding are essential for any organization, and with these reviews, RMC can help isolate items/coding practices that are in need of improvement.

A second reason to have a RA audit perform is to identify missed diagnoses codes (uncoded), which can equate to missed revenue. These missed codes or HCCs can then be reported, leading to higher reimbursement.

Lastly, for overall compliance, finding missed codes/HCC’s is important, but equally important is identifying HCCs reported that do not have supporting documentation. These reported codes, if left reported, will lead to over payments for the organization. RMC will assist our clients in identifying inappropriately reported codes/HCCs and recommend deletion. Although this is revenue that will be returned, it is the right thing to do. And compliant.

RMC HELPS YOUR TEAM IMPROVE DOCUMENTATION COMPLIANCE
When RMC performs HCC audits, we will look for ways to improve documentation. Which in turn may or may not improve revenue – but proper documentation is critical. RMC will locate areas that are deficient (i.e., coding, documentation, etc.), and with this information, education is then offered to coders, billers, and providers. Education based on audit results can lead to more compliant documentation and missed revenue.

By working with RMC, we’ll work with you on Risk Adjustment audits for either Medicare Advantage, HHS/ACA or both, depending on the need of the organization. RMC will help to ensure your documentation and coding practices are up-to-date, accurate and compliant.

Risk Adjustment/HCC reviews

  • Medicare Advantage (MA) Audits
    • Reviewing charts for Adds (missed codes, potential added revenue)
    • Reviewing charts for Deletions (codes where documentation does not support)
  • HHS/ACA Review
    • Reviewing charts for Adds (missed codes, potential added revenue)
    • Reviewing charts for Deletions (codes where documentation does not support)
  • HRADV Audits
    • Reviewing documentation to support HCCs

Education

  • RA education to coders/billers/QA staff
    • Coding education
    • RA/HCC Guidelines
    • Education based on audit/review
  • RA education to Providers
    • RA/HCC Guidelines
    • Education based on audit/review
      • Organization/facility education
      • Individual provider education
We’d love to talk with you about your coding and compliance challenges. Contact us today and let’s start a conversation.