EDPS
With EDPS, Coding
and Encounter Reporting are the two critical components of risk adjustment that
plans must address and master if they are to obtain the revenue they deserve
and require to ensure their continued viability and success.
Small differences in encounter acceptance have a large
impact on a plan’s revenue.
90% acceptance =
$244 95% acceptance=$258 99% acceptance = $269 - A difference of $25MM
If that is not
enough motivation, consider the 2013 OIG Work Plan
Encounter
Data—CMS Oversight of Data Integrity (New) –
We
will review the extent to which MA encounter data reflecting the items and
services provided to MA plan enrollees are complete, consistent, and verified
for accuracy by CMS. In 2012, MA encounter data reporting requirements will
expand from an abbreviated set of primarily diagnosis data to a more
comprehensive set of data. (One Time Notification, Pub. 100-20, CR 7562.) Prior
CMS and OIG audits have indicated vulnerabilities in the accuracy of risk
adjustment data reporting by MA organizations. (OEI; 00-00-00000; expected
issue date: FY 2014, new start)
Accurate Funding
Complete and
accurate medical records at the point of care provides better outcomes, improves the
experience of care, reduces costs and adds value to all stake holders. How much
money did you spend on chart reviews for “missed” diagnosis
codes? Consider the following example:
RISK Score
|
Baseline Revenue
|
Potential Increase
|
Potential PMPM revenue 100%
baseline
|
|
Present RAF
|
.8618
|
$676.92
|
||
Scenario 1
|
.90
|
$676.92
|
$53.59
|
$730.50
|
Scenario2
|
.95
|
$676.92
|
$94.17
|
$771.09
|
Scenario3
|
1.0
|
$676.92
|
$134.76
|
$811.67
|
Annual Attestation
MA Plans must certify that risk adjustment data is accurate, complete,
and truthful (based on best knowledge, information and belief) (42 CFR 422.504
(I))
This creates a duty to, at a minimum, “put in place an information
collection and reporting system reasonably designed to yield accurate information,”
including ordinarily conducting “sample audits and spot checks…to verify
whether the system is yielding accurate information
Kameron Gifford, CPC
www.ermconsultinginc.com
772-210-2823
kgifford@ermconsultinginc.com
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