Earlier this year, in response to an article from Kaiser Health News and the Center for Public Integrity, Senator Chuck Grassley (R-Iowa) penned a letter to Centers for Medicare and Medicaid Services Administrator Seema Verma calling for CMS to tighten their examination of Medicare Advantage fraud.

Increased scrutiny of MA practices is also evident in the form of a number of high-profile lawsuits.

Providers that need to ensure adherence to compliance rules can improve performance with the information technology tools they have in place, but IT isn’t sufficient alone to manage potential problems without an all-encompassing strategy.

Genomic analysis at the Broad Institute of MIT.
Genomic analysis at the Broad Institute of MIT.

MA plans use a mechanism called Risk Adjustment Factor (RAF) scores to determine the cost of care for patients, assigning a higher score to providers who care for more complex patient populations. As the RAF score increases, so does the amount Medicare pays to providers to appropriately care for their patients. And both providers and payers should be prepared for Medicare audits, called RAC and RADV audits respectively, which verify appropriate documentation to support RAF scores.

RAF is determined by a number of criteria, including Hierarchical Condition Categories (HCCs), a set of codes that designate a patient’s additional risk and complexities. Health systems working to more accurately document RAF can take a few lessons away from these lawsuits.

Providers need to demonstrate that any effort to improve risk capture is driven by accuracy, not just a goal to increase RAF scores (and respective reimbursement). This means focusing on closing care gaps and identifying codes with unsupportive documentation. The federal government is looking for the defendants to demonstrate formal processes for both.

To be effective in these endeavors, providers need to be intimately involved in the the risk capture conversation. Recent lawsuits signal to the industry that providers still have to be at the center of this process. Risk capture programs that depend on non-providers to manage HCC codes and problem lists run a greater risk of lacking sufficient clinical documentation.

How technology can make it easy for providers to do the right thing

The goal of documenting HCCs and an accurate RAF score isn’t just appropriate care funding. At heart, these mechanisms are designed to provide clinical value. In my work helping clients optimize their EHRs to capture HCC codes, I see examples of how technology can offer up the right data, at the right time, for life-saving results. In one case, the EHR flagged a previous thoracic aneurysm on the problem list that had been lost in the follow up documentation. This is a life-threatening condition that the EHR identified as a care gap.

The ideal role of technology, and specifically the EHR, is to make it easy for providers to uncover care gaps in patient populations and document risk with accurate, complete detail. Leveraged effectively, technology can help providers to identify HCCs with a higher probability of accuracy.

  • DO consistently serve gap recommendations to providers using algorithms that will identify higher probability conditions—and make it easy to appropriately code for them. Provide context for recommending a condition and prompt providers for confirmatory data within the clinical decision-making process.
  • DON'T scrape the bottom of the barrel to capture every last code if there’s less probability the condition actually exists. Technology’s responsibility is to offer up additional data to a provider but allow the clinical decision process to drive the diagnoses.

The EHR is not yet smart enough to document HCC codes in an automated way, so invest in human resources to make the most of what technology can do. Most health systems I work with have a robust Clinical Documentation Initiative (CDI) team on the inpatient side but have neglected ambulatory services. That’s a mistake.

  • DON’T rely on coders to review every chart and every claim. Although building out a coding team is an essential investment health systems should make, they are an expensive resource with the impossible task of catching every coding and documentation error.
  • DO empower your coding and CDI teams to use technology to focus review efforts on charts and claims most likely in need of additional documentation. Some companies use Natural Language Processing (NLP) to prioritize charts that may need additional review. In this case, the technology makes the coding staff more agile, proactive, and quicker to identify potential issues.

With the right guardrails and vigilance, the EHR can serve up appropriate data at the right time and streamline providers’ ability to do the easy and right thing. It isn’t technology’s job to take the decision-making process out of the providers’ hands, but to serve as an additional tool to enhance care delivery.

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