|
DID YOU KNOW: Certified RN-Coders are among the brightest and the best at ICD9/HCC chart reviews!
Whether your Medicare Advantage plan delivers the PCP or specialist charts by appropriate dates of service digitally, or you need the CRN-C reviewers to obtain relevant ICD9 for you at the medical offices or hospital, one thing is certain: Certified RN-Coders are your single best resource for ICD9 code validation for Medicare compliance!
The RN-Coder Network is the only company in the United States providing specially-trained RN coder-reviewers for Medicare Advantage plans. Currently we have over 1500 trained RN-Coders all over the US, ready and waiting to perform onsite chart reviews and digital reviews. Pricing varies by type of chart, location, total number of charts to be reviewed and timeframe.
A Southern California-based company, the RN-CODER NETWORK was established to assist physicians and Health Plans in obtaining full premium revenue for their Medicare Advantage members. The goal of the RN-CODER NETWORK is to help clients achieve accurate and complete documentation, diagnosis coding and reporting of their Medicare Advantage patients’ health status.With costs rising and revenue sources diminishing, Medicare Advantage Plans and their risk partners can ill afford to fail to identify their members’ relative severity of illness - the key to Medicare’s premium calculation. Accuracy in medical chart documentation is essential to proper and complete reimbursement for Medicare Advantage members. The RN-CODER NETWORK’s analytic software, developed by clinicians such as Internal Medicine physicians and RNs with extensive chart review experience with HCCs, helps Health Plans and their risk partners receive the full measure of premium revenue for their members.
THE RN-CODER NETWORK’s proprietary AUDIT-R software identifies "high-yield" charts, those charts most likely from a clinical and statistical point of view to contain overlooked data. AUDIT-R prioritizes the chart review list. The list includes the most likely yielding charts - typically 30% to 40% of all records. By eliminating up to 2/3 of the charts, Clients can choose the optimal point of their investment and maximize return by greatly reducing the time and expense required to review charts. When THE RN-CODER NETWORK's AUDITR coding software is employed by Certified RN-Coders, the chart review becomes focused and efficient. The results:
- Findings increase 40% over standard reviews by non-clinical coders
- Return on Client investment approaching 8 to 1 and higher
Organized by a team of HCC physicians, nurses, and managed care executives, the RN-CODER NETWORK has developed software and techniques to pinpoint diagnoses in the medical chart that have not been recorded or inaccurately recorded according to CMS guidelines. Our AUDIT-R AND REVIEW-R software programs integrate claims, encounter, and prescription drug data with hundreds of special algorithms to identify probable undocumented chronic conditions. The RN-CODER NETWORK's software based systems have dramatically improved members' risk scores.
“Lax Coding by Physicians Hurts Medicare Advantage Plans”
By assisting doctors, insurers can get all the payment that they are due, but that too often is lost
By Marcia Naveh, MD
Health insurers participating in managed Medicare have never experienced as wide a gap between actual and potential payment as currently exists. Simply stated, Medicare managed care payments from the Centers for Medicare & Medicaid Services depend on accurate and complete diagnostic physician coding.However, the economics of running a physician practice penalize those who take the extra time to code completely. The physician coding that health plans rely on to set their premium payment levels is incomplete and inaccurate, and as a result, many health plans currently receive dramatically lower premiums than those to which they are entitled. That need not be the case, however.
RECENT HISTORY
Ideally, plans that enroll more complex patients will receive higher premiums from Medicare to provide the necessary services. Proper HCC classification depends on both a plan’s ability to obtain accurate diagnostic information and a plan’s ability to report that information accurately to CMS. Although this sounds simple, it has proven to be quite challenging from both an operational and clinical perspective.
Obtaining the complete diagnosis data needed for accurate risk adjustment is fraught with challenges. CMS accepts information regarding a member’s health status from limited sources, one major one being medical charts from physician offices.
Unfortunately, physicians are not trained or motivated to document the complete spectrum of applicable diagnosis codes during an office visit, as only one valid diagnosis code is required for the physician to receive compensation.
The health plan, however, must obtain every existing diagnosis coded in order to obtain an appropriate risk score and receive proper payment from CMS. Failure to do so can cost plans millions of dollars per year that could be used to provide needed medical services to members.
Consider: A patient has a cold but has suffered a previous stroke, is diabetic and has Parkinson’s disease, congestive heart failure, and high blood pressure. The physician is paid based on whether the visit is short, medium, or long, and she codes one diagnosis: upper respiratory infection. While the physician is paid correctly for the visit, the plan may not get paid the proper premium if the physician fails to report a code or does not provide the necessary specificity in coding to document the complexity and anticipated cost of the disease.
In all likelihood, this patient will be hospitalized, perhaps incurring a catastrophic two- or three-week stay in the intensive care unit. Because this member’s risk score was never properly obtained, the MA plan did not accumulate the necessary reserves to provide for this event.
Now let’s suppose that the physician is trained to perform a comprehensive evaluation of all relevant diagnoses and properly documents each relevant diagnosis code. The next challenge is to get that information to CMS. Under the HCC system, patients with complex medical problems are at highest risk of being scored too low in the risk assessment.
Such patients can require 10 to 20 ICD-9 codes to accurately reflect their health status. Because most medical billing intermediaries (clearinghouses) truncate after four ICD-9 codes, these patients at highest risk will not have their risk adjusted properly, and, once again, the plan will not receive the appropriate payment.
FINANCIAL PENALTY
From a clinical perspective there are more serious challenges. Under Medicare+Choice, health plans were penalized financially for enrolling sicker members, because payment did not reflect complexity. Under HCC methodology, plans have an incentive to enroll sicker members. Assuming ideal circumstances, a Medicare Advantage plan has processes in place to ensure both comprehensive diagnosis coding and accurate submission to CMS.
But those are ideal circumstances.
Does your MA plan have access to the necessary robust resources (hospitals, nursing homes, home care, case management, disease management) to manage the complex medical needs of the population it now insures? More importantly, does the health plan have the technology to identify the patients who would benefit from additional resources and monitor their utilization and progress? Under the HCC risk system, it is essential that plans deploy all necessary resources to achieve better outcomes and avoid catastrophic events.Although the challenges of the HCC system are daunting, the system offers significant rewards and opportunities for plans willing to embrace the change. CMS has stated that the Medicare Modernization Act is a budget-neutral program. Total premiums distributed to participating Medicare Advantage plans will not be allowed to increase under the HCC payment system. How the premium dollars are divided among the plans will, however, change dramatically.
PROFITABILITY
There is a lot of money at stake. Al Lewis, president of the Disease Management Purchasing Consortium, says, “Average plans are leaving significant revenue on the table by not providing CMS with a complete and accurate listing of ICD-9 codes. When payments from the government are only increasing 2 percent to 4 percent per year and medical costs are increasing at a much greater rate, plans must improve the coding of members to remain financially viable.”
Plans that focus on cost-management strategies such as disease management and ignore the need for income management in the form of an effective HCC strategy are missing the big picture. “Best practices in a disease management program can save perhaps $200 per high-risk Medicare life,” Lewis explains. “Yet from a coding perspective, these plans are often paid $2,000 less than they should be paid for these members because of under-reporting of ICD-9 codes.
So, coding is 10 times as important as disease management, yet plans are probably spending 10 times as much on disease management as on coding.” In addition to increasing their revenue, plans that embrace an HCC strategy are likely to achieve better outcomes. By using rigorous and comprehensive health assessments, members with underlying health conditions stand a greater likelihood of those conditions being identified. They can then be channeled into proper disease management programs.
Members taking several medications are also more likely to get the attention they need to address their poly-pharmacy risks when coding has been addressed. As physicians complete more comprehensive reviews, they can look at a member’s medications more rationally and see which medications are really needed and which are not. After all, more drugs mean higher risk of adverse effects, higher potential for medication errors, and an increased risk of negative drug interactions. Fewer unnecessary and inappropriate drugs means lower costs.
Certified RN-Coders, trained in documentation of drug dosages and drug management for chronic illness, are far more likely to obtain correct ICD9 codes for chronic & Rx HCCs from a PCP or specialty chart than a non-clinical coder.
Effective MA plans will also identify ways to reach out to members who see a physician only when they have a crisis. Bringing these members into the fold will not only improve their health status but also will provide the plan with accurate risk profiles. Furthermore, these members will become less likely to utilize costly emergency services.
For plans that have already implemented an HCC strategy, that strategy will require constant evaluation, regular modification, and lots of training. For plans that have chosen a “wait and see” approach, now is the time to act. Given the uncertainty of future premiums and escalating medical costs, it is critical for plans to be paid properly for their membership.
IMPLEMENTATION
There are two phases to creating a solid strategy. The first is the retrospective phase, whereby the plan utilizes clinical coders and sophisticated algorithms to find unreported diagnosis codes by searching through medical charts. This involves pulling large numbers of charts from physician offices to secure codes that have not been submitted to CMS.
The second phase is the prospective phase. Plans train physicians in their network to provide complete and accurate lists of all relevant ICD-9 codes for each member encounter. This approach improves the plans’ ability to capture accurate data and eliminates the need for expensive retrospective chart reviews in the future.
In the retrospective phase, a plan can become overwhelmed by the tedious nature of reviewing large numbers of medical charts. Therefore, it is important to stratify the population from highest risk to lowest risk, from an HCC perspective. Specially-trained RN-Coders are uniquely qualified to verify and/or locate additional chronic ICD9 codes.
“Locating Competent RN-Coders Has Never Been Easier Or More Cost Effective”Do Certified RN-Coders cost the plan more? Our per-chart review costs are among the most competitive in the US. When you consider the additional efficiency and revenue they will bring into the plan. You will see just how cost-effective RN-Coders can be. And because they are out-sourced, there is no additional cost of payroll taxes, benefits, or vacations. Our unique online scheduling and data-gathering tools, which will provide all validated or acquired relevant ICD9 codes in the correct RAPS format, enables your project managers to literally watch our progress as it unfolds.
“Providing Consistent and Predictable Results"
All of our RN-Coders have passed a rigorous national coding certification exam and are highly competent with numerous years of specialty clinical experience. They are qualified to assist your plan with implementation of new HCC systems or sustaining current systems to ensure quality diagnostic coding of your members’ chronic conditions.
We understand your needs and are committed to your success! Please call the RN-Coder Network today, as we are currently scheduling for the January 2009 CMS deadline for 2007 dates of service: 909-579-0507 (M-F, 9am-4pm pacific) for details.
Joyce L. Thomas, MHA, CPM, CPC, CCC-Advanced
President & FounderThe RN-Coder Network
1142 S. Diamond Bar Blvd. Suite #796
Diamond Bar, CA 91765
About Joyce L. Thomas, MHA, President:
Graduating from the University of LaVerne in 1987 with a Masters in Healthcare Administration (MHA) degree, Joyce is a former medical practice administrator with extensive experience in physician and outpatient coding. She has developed the RN-Coder and RN-Auditor Institutes, curricula which trains Registered Nurses in an accelerated format the basics of Medicare-compliant coding and chart audit, which has resulted in over 5,000 RNs being trained since 2001. Joyce is also the Executive Director of the American Association of Clinical Coders & Auditors, a non-profit, tax-exempt 501c6 professional organization, which is the only group in the US certifying RNs and other clinical personnel (such as physicians, physician assistants, physical therapists) in coding compliance with a computer-based exam. Joyce assisted Maxicare in recovering over $4 million on a Medi-Cal stop-loss contract – and most recently assisted HealthNet in several arbitrations, saving HealthNet over $14 million. Having worked with Ernst & Young as a health care consultant, Joyce has also served as an expert witness for healthcare plans requiring testimony on proper coding and reimbursement. Her clinical background is in midwifery, primarily in assisting women in out-of-hospital births. Joyce and her husband Carl live in Southern California, and she is the mother of two grown daughters and two sons (Jaye, 21 a college student and Jordan, 11 are still at home) and grandmother to Moira Elisabeth, who at 14 just started high school.
