Healthcare Payers >
Medicare Risk Adjustment Audit &
Analysis
CMS currently uses
a risk adjustment payment method for
their Medicare Advantage (formerly
Medicare + Choice) enrollees. The
program is based on a set of
Hierarchical Condition Categories (HCC)
designed to pay the health plans an
adjusted payment to account for care for
the plan's sickest beneficiaries. CMS
uses Risk Adjustment Data captured from
claims data and submitted by Medicare
Advantage Plans to group patients into
Risk Adjustment Categories and to assign
payments based on the member’s
condition. In addition to assuring the
accuracy of Risk Adjustment Data, plans
must stress the importance of providers
submitting accurate and valid diagnosis
codes, substantiated by documentation in
the medical records on the claims.
Incomplete or inaccurate data could
cause plans to receive lower
reimbursements for their members.
EpiSource’s team consists of clinical
and certified coding experts with
extensive experience in conducting
medical records reviews for impatient,
outpatient, and physician services. Our
data analytical team has experience in
analyzing data from a variety of
sources, including physician data,
hospital inpatient and outpatient data,
enrollment data, medical records review
data and fee-for-service data.
Episource, using its AAPC certified
medical coders and clinicians provide
the following services:
• HCC Risk Score Calculations for
Enrollees (RAF)
• Risk Adjustment Payment Calculations
• Provider-wise reports indicating level
of HCC coding and diagnosis reporting
• Physician Education on Diagnosis
Reporting
• Chart Audit for accurate documentation
and reporting of ICD-9 CM Codes
(Diagnosed and Not Coded /
Inferred – Suggested and Not Coded)
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