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Since the 21st Century Cures Act (CCA) was passed in 2016, there have been several changes to the existing risk adjustment model. Over the next few years, and until the Alternative Payment Condition Count (APCC) is fully implemented in Payment Year (PY) 2023, we expect to see even more.

CMS’ Advance Notice part 1 came as no surprise to the industry. Since the 2019 final notice, CMS has advised on the implementation of the 21st Century Cures Act, which requires that any changes made be phased in within 3 years. The phase in period began last year in Payment Year (PY) 2020 and is proposed to be completed by PY 2022. 

Despite the challenges health plans are now facing, there are several ways to maximize medical chart retrieval, streamline the process from analytics to submissions, and optimize risk adjustment performance before the January deadline. Here are 5 tips to consider.

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.