The RCxRules Blog

An Expert’s Take on HCC Coding

Meet our Guest Writer: Kate Casaday 

Kate Casaday is the Chief of Staff and Executive Director of Program Management at On Belay Health Solutions. She previously worked on Optum Care's ACO REACH program and full-risk MA partnerships in the Tri-State region. Prior to that, she stood up the Next Generation ACO program and Direct Contracting as an early hire on CareMount Value Partners MSO's Medicare risk team. She earned a Masters of Public Health from Columbia and an MBA from The Wharton School.

 Value-based care is complex, and medical groups have multiple ways to create value during the risk adjustment process. The three main methods are:

  • Pre-visit chart prep
  • Concurrent review
  • Retrospective review

Kate breaks down the pros and cons of each in our latest whitepaper. Below is an except outlining her view on the concurrent review process.

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Concurrent Review

In a concurrent coding review process, coders review the EHR medical notes and HCC codes in real time before the claims are submitted to payers. A significant benefit of a concurrent review process is the speed of mark up. You can get feedback into the hands of a provider very quickly and drive behavior change through repeated stimulus and response.

Doctors went to school for a long time and excel at learning—when they’re given the right information they’re going to pick up on patterns really quickly and alter their behavior accordingly. This behavioral change aspect is unique to concurrent review. The ability to get feedback to a provider right away and improve documentation prior to filing is a game changer. You can’t really achieve that feedback model with any other review process.

Another strong argument in favor of concurrent review is the accelerated accruals and leading indicators for risk score forecasting. Accurately forecasting risk adjustment scores is extremely difficult. Concurrent review gives you real-time data that can be leveraged immediately, as opposed to other workflows where the data lags behind and may be less useful a few months after the fact.

The concurrent review process also offers an early reduction of compliance risk. Including the correct HCC code on the initial claim is a safer option than adding or deleting an HCC after submission. By including all relevant information—and ensuring it’s correct—the first time, you can reduce your audit risk.

As valuable as the real-time feedback process is, it can also become a negative if isn’t handled in a way that’s efficient for both coding staff and providers. It’s important to avoid a situation where the learning and behavioral changes become a burden that doctors don’t want to deal with. The key lies in creating as frictionless an experience as possible. The feedback element is also a qualitative process, which can make it difficult to translate into financial terms.

Another potential issue is the negative impact on fee-for-service A/R. If you tie up a claim for a week waiting for a provider to respond, you can complicate things. When there’s fee-for-service and shared savings (with an ACO for example) holding up claims, it can delay fee-for-service revenue.

To learn more about why a concurrent review process is a better workflow option than prospective or retrospective reviews, download the full whitepaper.

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