Arizona Community Physicians Improves Coder Productivity and HCC Accuracy - Key Factors in their Medicare Shared Savings Program Success

The Challenge

Arizona Community Physicians (ACP) is a leader in value-based care. Their Accountable Care Organization (ACO), Abacus Health, was selected to participate in the Medicare Shared Savings Program (MSSP) beginning on January 1, 2016.

During their first two years in the MSSP, ACP deployed a six-step manual process for 12 of their 53 locations to ensure appropriate and accurate HCC codes. Managed by three full-time ACO employees, the process was designed to review all medical records as well as associated claims.

This manual process proved to be inefficient, error-prone, and stressful for coders. Coders were constantly rushing to review claims and medical records for HCC accuracy so claims could be sent to payers. Often incorrect claims were discovered that had already been sent to payers, and coders had to spend additional hours working with the billing team to correct and repost them.

Extending this manual system to cover all 53 locations while maintaining a thorough HCC process would have been even more inefficient and costly. ACP clearly needed a better solution.

THE GOAL: reduce time spent on HCC coding review, minimize costs, and streamline operations while maintaining or improving HCC accuracy.

The Solution

By leveraging the RCxRules software to automate their pre-claim coding review process, ACP significantly reduced the time and resources required to perform their comprehensive HCC review process, while improving accuracy. That’s because RCxRules’ intuitive rules engine:

  • Automatically reviews every encounter that is finalized in the EMR
  • Identifies encounters that may warrant a more accurate and specific diagnosis code
  • Uses workflow automation to send exceptions to coders for review and revision

Results

  • Higher Productivity: The manual review process previously required 3 FTEs for 12 sites. The new automated process only requires 2 FTEs to cover all 53 sites.
  • Improved Accuracy: RCxRules’ powerful rules engine eliminated the need for a post-claim/retrospective review process.
  • Peace of Mind: By automatically reviewing all claims before submission, the HCC scrubbing capabilities of the rules engine led to greater confidence—and fewer headaches.


 

About Arizona Community Physicians

ACP is Arizona’s largest physician-owned medical group, with 53 locations in Tucson, Oro Valley, and Green Valley. With approximately 800 employees and 166 multi-specialty providers, ACP pride itself on its patient-centric approach and commitment to create a healthier community. ACP formed Abacus Health to improve patient care and recognize providers for the good work they do.

 

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