In healthcare, teamwork means success. To do this, everyone on the team needs to be on the same page regarding the clearly-defined goals, consistent workflow processes, smart metrics, and use of relevant tools that support the above.
All healthcare organizations that cater services to patients with Medicare coverage benefits through the Medicare Advantage (MA) program, which in this case, is almost 100% of the time, should have access to tools and programs that make hierarchical condition category (HCC) coding time efficient and accurate. From the Centers for Medicare & Medicaid Services (CMS) 2004 HCC risk-adjustment model to medical coding utilizing the ICD-10 code set to the now better healthcare predictive tools that use natural language processing (NLP), these updates give greater accuracy in handling claims and reimbursement data. This preciseness in assigning values for risk adjustment factor (RAF) scores improves the team’s performance.
The above statements benefit the organization, but how is this relevant to patients? It also dramatically impacts the Medicare beneficiaries because, in value-based care, patients are assured of maximized coverage in their healthcare benefits, giving them a reasonable calculation of their coverage amount each year. In this way, it helps them focus on their health and recovery.
We’ve established the benefit of using accurate RAF scores for the organization and patients, but how do these impact healthcare providers? At first glance, it looks like none; it also appears that the burden of work is on the physicians, nurses, and other healthcare allied service providers. Let’s take a closer look at some HCC coding best practices and guidelines to establish the advantages.
Clarity of roles
Everyone on the team is vital, but one critical role is the HCC Coding Specialist or the leader in each organization that will be overseeing HCC coding practices (regardless of title). This person will be considered an expert in the field and take on the team lead role. The specialist’s presence will dictate the entire team’s success and direction. Patient RAF scores will be accurate, therefore, ensuring quality clinical care and experience for patients, minimized budget losses for the organization, higher income for the physicians, and better performance and motivation for the entire healthcare team.
With the leadership of the HCC Coding Specialist (supervisor or leader), workflow processes can improve by including plans for training for everyone. Continuous training and education on HCC coding updates and guidelines are crucial to minimize errors in coding and lower the RAF scores.
Monitoring and reporting
In healthcare, data is critical! So the team needs to use it accurately and timely. If it’s not automated yet, it is high time to consider this feature. Value-based programs need to have real-time reports updated daily. This gives a better view of the effectiveness of physician management, timely adjustment of medication and treatment as necessary, better experience in patient care, improvement in daily operations, and most importantly, accurate costs, assuring better reimbursement for the physician groups.
Accurate patient data
If data is critical, everyone on the team must focus on making it complete, concise, and clear-cut. The team plays a significant role in making all information very accurate regarding medical histories, modality of treatments, procedures, and, most significantly, all pre-existing chronic conditions that need to be listed and indicated. Because false or incomplete patient information will result in wrong documentation, erroneous or incomplete treatment modalities and procedures, and incorrect HCC codes, this, in turn, will raise the risk adjustment factor and inflate Medicare costs.
In cases of an initial patient visit, it is just as crucial for the team to sweep through all the relevant questions and complete all information so that physicians can provide correct, better, quality care and maximized coverage. The result in efficiency means an increase in the physician’s earnings.
Government Funding for Insurers
In this section, let’s talk about the role of government funding and how it can benefit all stakeholders, including the patient, healthcare team, private insurance companies, and even the government itself. RAF scores can dictate government expenditure, which the population’s health and funding are heavily reliant on. On the other hand, private insurance companies rely on an increase in government funding from member claims and reimbursement. Achievement of both goals benefits the patients.
But how can these ideals be achieved? It can only be possible with timely and accurate RAF scores for each patient claim. All patient information and health records must be carefully filled up and updated. Equally important to note is the RAF benchmark score used for each specific region or state; because the benchmark scores vary depending on location. As led by the HCC Coding Specialist, the healthcare team needs to keep abreast with the latest updates from CMS.
As an example, in 2019, CMS released an update that the Medicare Advantage program has decided to include non-health benefits like meals, transportation, grocery shopping, and even home environmental services to their members. This is good news for insurance companies, but to maximize claims reimbursement from the government, the patient data and HCC coding need to be 100% accurate, especially if the member has a chronic illness.
Otherwise, insurers will lose the opportunity to get funding for undeclared chronic illnesses. Because chronic conditions significantly affect the RAF scores and if not properly documented and updated, reimbursement claims cannot be maximized. It is especially worth noting for elderly members who might have chronic conditions like simple vertigo that symptoms just come and go away on their own. But, when it manifests, it can affect work and the activities of daily living. Therefore, this condition needs to be updated in the patient record so that non-medical claims like meals and grocery shopping can be added.
It is also imperative that a regular, yearly assessment of the patient’s condition be done. This benefits both the insurer and the member. The patient gains a better quality of life from early treatment if complete healing and recovery are impossible. On the other hand, the insurer gains higher funding for maintaining an updated database of patient records.
By and large, it can be boldly said that this also benefits the government because the goals of the health programs can be successfully achieved and the health budget and expenditure adequately appropriated.
Success in healthcare results from a well-structured process, an efficiently functioning team, and an accurate method to measure key results.
Finally, use the MEAT (monitoring, evaluation, assessment, treatment) Criteria Model for coding, which is an excellent tool for monitoring key results; to do this, partnering with organization experts like Inferscience can help all stakeholders by providing a software tool that can accurately automate coding, using the HCC Assistant.
Consider the HCC Assistant app that uses predictive natural language processing (NLP) to help improve HCC coding and results in better Physician Group’s RAF Scores. One of the benefits of partnering with InferScience is gaining access to various HCC Utilization reports that will give you an accurate picture of physicians’ participation in HCC coding & risk adjustment workflows and identify whose HCC utilization is low so that adjustments and necessary training are put in place to improve their performance, and ultimately increase the physician group RAF scores.