The RCxRules Blog

Why Medicare Advantage Organizations Do Retrospective Chart Reviews to Improve RAF Scores (and What Medical Groups Can Learn from Them)

Medical groups face many challenges when it comes to risk adjustment—particularly regarding providers and coding. We often hear that providers are good at documentation but may struggle to capture and code chronic conditions. This is a concept that Medicare Advantage Organizations (MAOs) have been aware of for years. MAOs know that provider documentation is often more robust than the coding reflects—and they’re very aware of the impact this can have on accurate RAF (risk adjustment factor) scores. To combat these potential coding gaps, many MAOs invest in a retrospective chart review process. Medical groups can learn a lot from their approach to improving risk adjustment efficiency and performance.

RAF Scores and Medicare Advantage

Why do Medicare Advantage Organizations invest in retrospective risk adjustment chart reviews? RAF scores determine how MAOs get paid—so ensuring accuracy is crucial. Retrospective chart reviews can help MAOs improve the accuracy of risk-adjustment payments by allowing them to add and delete diagnoses in the encounter data based on a patient’s medical records in the EMR. This helps ensure that MAOs that enroll sicker beneficiaries are appropriately compensated for their more costly levels of care.

MAOs know that coding is hard for medical groups. As explained in a recent article from Modern Healthcare:

“Risk-adjustment coding is critical to the success of a Medicare Advantage plan and relying on the diagnostic codes that providers submit won't cut it…. ‘Doctors are terrible at this. Doctors see patients, and coding is complicated and esoteric,’ said Dr. Mario Molina, former CEO of…insurer Molina Healthcare who now heads up Golden Shore Medical, a chain of California clinics. ‘Theoretically you should be able to get all the info from the claims data, but health plans hire coders or nurses to look at the chart and find things they can take credit for and get paid more.’”

Retrospective chart reviews have been shown to significantly increase payment. According to healthcare analytics and technology company Pareto, for a 50,000 member MAO, improving year-over-year recapture of chronic conditions, even by only 3% (for example going from 82% to 85%), can result in approximately $10 million in additional annual revenue. MAOs are investing a lot of money in chart reviews and seeing an ROI. It’s clear the documentation is robust enough for more effective risk adjustment coding.

Key Learnings for Medical Groups

As Medicare Advantage Organizations have known for years, providers often have robust documentation but lack in risk adjustment coding. There’s a significant opportunity for medical groups to create a stronger HCC coding review process to avoid having to rely on the retrospective review process used by MAOs.

A stronger risk adjustment coding review before claims are sent to the payer will ensure correct HCC coding the first time. Many refer to this as a concurrent coder review. It results in more accurate payments from payers and will help groups avoid a lot of unnecessary back and forth in the form of paperwork and record pulling. Capturing the information correctly the first time will ensure groups have the information they need for continual year-after-year recapture. To be successful in the long run, medical groups need a comprehensive view of their patients’ HCC data.

For most MAOs, capturing HCC codes is a matter of when, not if. Either the medical group will capture the HCC code before a claim is submitted, or MAOs will find them after the fact. A concurrent and thorough HCC coding review process of provider documentation can have a big impact and reduce a lot of administrative work—saving the time, money and headaches that come with going back and forth with the MAO.

RCxRules can help with concurrent HCC coding review and is proven to improve HCC code capture. Set your group up for continual success with year-after year-recapture: set up a 1:1 meeting to learn more. RCxRules Product - Learn More Image CTA - Version 3-2

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