Lovelace Health Plan
Company Profile
- Founded in 1973, Lovelace Health Plan offers a diverse range of managed care plans, providing insurance coverage for more than 190,000 people across the state of New Mexico
- Health Plans cover more than 2,000 employer groups and thousands of Medicare-eligible individuals and their families
- Members have access to a large network of physicians and health care centers providing benefits such as preventive programs, emergency care, urgent care, and out-of-state coverage
- Lovelace offers a Medicare Advantage HMO (Lovelace Senior Plan) with a Medicare contract offering complete healthcare coverage to senior members in place of Medicare coverage
Business Situation
Facing the challenge of lower risk adjustment revenue from CMS and the possibility of losing money from RADV audits, Lovelace was looking for an outsourced solution to help its coding department focus on quality and accurate HCC Code submission. From there, they knew that they wanted to find a partner that could perform the work that met their specific needs:
- Provide a high level of service and accuracy for a good price
- Find an organization that was easy to work with, flexible, and highly process oriented
- Work with a partner that was able to scale quickly to handle large volumes of charts
- Review from EMR systems as well as scanned medical records
- Meet CMS sweep deadlines for HCC submission
- Focus more on provider education to help improve coding and chart documentation
- Meet CMS Coding Guidelines
HCC Codes submitted by providers were to be validated with chart documentation and any supplemental HCC Codes identified were to be reported back to the Health Plan. Chart documentation issues were also to be highlighted to help focus more on provider education and improved RAF scores.
Solution
Episource, having a strong team of offshore CPC Certified Medical Coders, was able to provide a cost effective and quality solution to meet Lovelace’s requirements. Episource’s coding team worked closely with the Risk Adjustment coding department at Lovelace Health Plan to outline project requirements such as FTP access to scanned images and data output files, and EMR access. Through regular weekly conference calls, both companies were able to agree on coding guidelines and processes to be implemented for the project including all elements to be captured on the data output file which included comments for chart documentation issues. In addition to HCC Codes identified on each chart,
Episource also validated HCC Codes already submitted by providers through claims data files. This would help identify any incorrect HCC Codes submitted.
To ensure accurate code capture and quality, Episource dedicated a separate QA team to audit 100% of all charts reviewed. Despite a two-tier system for coding, Episource was able to deliver all submission timely to meet CMS deadlines. Quarterly Inter-rater reliability audits were conducted by Lovelace on Episource coded charts to monitor compliance and quality objectives. Episource always scored over 95% in terms of accurate code capture. Similar IRRs were conducted internally on a weekly basis at Episource to maintain the same norms as described above.
Highlighting provider documentation issues such as missing signatures, illegible writing, missing dates of service, and coding-related issues regarding code specificity and linkage helped Lovalace’s Risk Adjustment department to focus more on educating providers to improve their chart documentation to help the health plan better account for cost of care to CMS.
Benefits
- Cost Savings of 40% for HCC Coding services by using offshore certified medical coders
- Over 20% improvement in RAF Scores
- Accurate HCC Code Capture due to 100% Quality Audit
- Time to Focus more on core activities such as data analytics and provider education
- Skilled resources to code from EMR systems
- Scalable resources to handle large volumes and meet CMS sweep deadlines
