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Clinical suspecting is the process of identifying possible conditions that are indicated in clinical data but remain undocumented. By reevaluating member data, plans can conserve revenue through preventive interventions and ensure accurate reimbursement in future CMS payments.

The HCC Risk Adjustment Model released this April by the Centers for Medicare & Medicaid Services for payment year 2020 includes important revisions coders should be aware of. In an effort to support coders and plans working within the updated model, we’ve described several examples of coding errors and ways to resolve them.

As your organization looks toward 2020 PY, implementing the new APCC model, and understanding how it will affect risk scores, there is still time to look at 2019 PY, conduct retrospective chart reviews, capture the new HCCs, and implement a plan for the future.

There’s no doubt Medicare Advantage plans and other risk bearing entities have heard about ICD-10 combination codes, but with the increased amount of single ICD-10 codes over the past few years, it’s crucial that they understand why and how to assign them.

Year-round analytics are fundamental to a full, accurate reimbursement. The success of this method lies in consistency.

According to recent data, there are 59.7M Medicare beneficiaries. Approximately 32% of those beneficiaries are under 200% of the federal poverty level and are potentially eligible for Medicaid. Although the number of enrolled dual eligible members has increased from 8.6M in 2006 to 12M in 2017, there is still a significant amount who are currently unidentified, representing a tremendous opportunity for health plans who need to implement or optimize their campaigns.

Working with a risk adjustment vendor can help ACOs accurately capture HCCs as they tackle the risk adjustment process for the first time. Here are questions to ask a potential risk adjustment vendor.

In April, when CMS released the 2020 Medicare Advantage Rate Notice and Final Call Letter and confirmed the Alternative Payment Condition Count model for 2020 CY, some changes were included in their original proposals, while others came as a surprise to health plans. As you look to evaluate your technology, analytics, processes, and solutions, here are 4 things you should know.