Upcoming V28 Risk Adjustment Webinars

Are you looking for the BEST V28 Risk Adjustment Education? If so, GREAT NEWS – you found it! Register today for the ALL NEW V28 Webinars. Tickets are $29.99 each – Bring the team and receive a 10% discount when you purchase 3 or more tickets for any event. All webinars are approved for 2 AAPC / AHIMA CEUs.

 

June 24, 2023, 2:00 PM to 4:00 PM – Introduction to V28 Risk Adjustment

Registration Link: https://events.eventzilla.net/e/introduction-to-v28-risk-adjustment-2138590700

Agenda:

• Discuss the NEW V28 CMS Risk Adjustment Model.
• Review Updated HCC Categories and Diagnoses.
• Key Steps to Take Now for Success in 2024.
• Approved for 2 CEUs from AAPC / AHIMA.

 

July 22, 2023, 2:00 PM to 4:00 PM – Master HCC Coding for V28

Registration Link: https://events.eventzilla.net/e/master-hcc-coding-for-v28-2138590697

Agenda:

• Discuss the Rules of the Road for Risk Adjustment.
• Review the Most Common HCCs per MedPac.
• Master Documentation and Coding for HCCs in V28.
• Approved for 2 CEUs from AAPC / AHIMA.

 

August 26, 2023, 2:00 PM to 4:00 PM – V28 Risk Adjustment Optimization

Registration Link: https://events.eventzilla.net/e/v28-risk-adjustment-optimization-2138590696

Agenda:

• Calculate Risk Scores and Payments for V28.
• Identify Potential Areas of Impact in 2024.
• Steps to Optimize Risk Adjustment Operations.
• Approved for 2 CEUs from AAPC / AHIMA.

 

Learn more www.ermconsultinginc.com

Coding from the Problem List or Past Medical History

Over the last few weeks I have received so many emails from coders with this question, “Is it okay for my team to code for conditions listed in the problem list or past medical history only? If not, why? Can you send me a guideline?”

The answer is NO – Your team should NEVER code for conditions that are listed in the problem list or past medical history only. Why? Per ICD-10 Coding Guidelines, codes should only be assigned for documented conditions that coexist at the time of the encounter/visit, and require or affect patient care, treatment, or management.

Coding professionals should not assign codes based solely on diagnoses noted in the history, problem list and/or a medication list. It is the provider’s responsibility to document that the chronic condition affected care and management of the patient for that encounter.

If the medical record is unclear or ambiguous regarding which condition(s) affected patient care and /or management of the patient, query the provider for clarification.

There is overwhelming evidence to support this practice.  

Download / view additional here https://erm365.org/coding-from-the-pl-or-pmh-only/

Key Litigation and Audits involving Risk Adjustment

If you work in risk adjustment - you should be familiar with these cases. 

• On May 30, 2017, Freedom Health Inc., a Tampa, Florida-based provider of managed care services, and its related corporate entities (collectively “Freedom Health”), agreed to pay $31,695,593 to resolve allegations that they violated the False Claims Act by engaging in illegal schemes to maximize their payment from the government in connection with their Medicare Advantage plans, according to the Justice Department.

• On October 1, 2018, HealthCare Partners Holdings LLC, doing business as DaVita Medical Holdings LLC (DaVita), agreed to pay $270 million to resolve its False Claims Act liability for providing inaccurate information that caused Medicare Advantage Plans to receive inflated Medicare payments, according to the Justice Department. DaVita is headquartered in El Segundo, California. 

• On April 12, 2019, Sutter Health LLC, a California-based healthcare services provider, and several affiliated entities, Sutter East Bay Medical Foundation, Sutter Pacific Medical Foundation, Sutter Gould Medical Foundation, and Sutter Medical Foundation, agreed to pay $30 million to resolve allegations that the affiliated entities submitted inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans, which resulted in the plans and providers being overpaid.

• On December 10, 2019, the OIG published a report, “Billions in Estimated Medicare Advantage Payments From Chart Reviews Raise Concerns”. The OIG found that diagnoses MAOs reported only on chart reviews-and not on any service records-resulted in an estimated $6.7 billion in risk-adjusted payments for 2017.

• On March 27, 2020, Geoffrey S. Berman, the United States Attorney for the Southern District of New York, announced that the United States filed a civil fraud lawsuit against Anthem, Inc. (“Anthem”), alleging that Anthem falsely certified the accuracy of the diagnosis data it submitted to the Centers for Medicare and Medicaid Services (“CMS”) for risk-adjustment purposes under Medicare Part C and knowingly failed to delete inaccurate diagnosis codes.  As a result of these acts, Anthem caused CMS to calculate the risk-adjustment payments to Anthem based on inaccurate, and inflated, diagnosis information, which enabled Anthem to obtain millions of dollars in Medicare funds to which it was not entitled.

• On June 23, 2020, Aveta Inc. and a whistleblower settled a False Claims Act suit alleging that its Medicare Advantage plans collected $1 billion in government overpayments, ending a dispute that served as an early test for litigation involving risk adjustment fraud.  

• On August 5, 2020, a whistleblower case filed by the Department of Justice was unsealed. The complaint accuses Cigna of fraudulently overbilling for its Medicare Advantage plans. A former service provider for Cigna’s Medicare Advantage subsidiary alleged that the company sent providers to patients’ homes to conduct a health assessment, which was then improperly submitted to the Centers for Medicare and Medicaid Services for risk adjustment. Allegations include claims the company submitted unsupported diagnoses that resulted in “billions” in overpayments. Litigation is ongoing - 7:17-cv-07515-KMK-JCM United States of America, EX REL. Robert A. Cutler v. Cigna Corp. et al.

• On November 16, 2020, Kaiser Foundation Health Plan of Washington, formerly known as Group Health Cooperative (GHC), agreed to pay $6,375,000 to resolve allegations that it submitted invalid diagnoses to Medicare for Medicare Advantage beneficiaries and received inflated payments from Medicare as a result, the Justice Department announced.

• On April 19, 2021, the OIG published an audit of diagnosis codes that Humana submitted to CMS for one contract. The OIG recommended that Humana refund to the Federal Government the $197.7 million of net overpayments and enhance its policies and procedures to prevent, detect, and correct noncompliance with Federal requirements for diagnosis codes that are used to calculate risk-adjusted payments.

• On July 30, 2021, the United States intervened in six separate False Claims Act (FCA) whistleblower cases alleging Medicare Advantage fraud.  The lawsuits allege that Kaiser Permanente and several of its medical groups knowingly submitted inaccurate diagnosis codes for their Medicare Advantage Plan enrollees.  The suit alleges that Kaiser did this to receive higher reimbursements from the government. Litigation is ongoing in all cases. 

• On August 30, 2021, the government announced a $90 million False Claims Act settlement with California-based health care services provider Sutter Health.  The settlement resolves allegations that Sutter knowingly submitted inaccurate diagnosis codes for beneficiaries enrolled in Medicare Advantage Plans.  This inaccurate information led to inflated payments to Medicare Advantage Plans and Sutter Health.

• On September 14, 2021, DOJ filed a Medicare Advantage fraud lawsuit against Independent Health and its former CEO.  Independent Health offers two Medicare Advantage Plans in New York State.  The United States has also sued Independent Health’s subsidiary, DxID.  DxID provided retrospective chart review and addenda services to Independent Health and other MA Plans. The case is captioned United States ex rel. Ross v. Independent Health Association et al., No. 12-CV-0299(S)

The BEST Risk Adjustment Education

 

Are you looking for the best education available in risk adjustment, value-based payments and/or CDI? Good News - You have found it!

Join us for a day of risk adjustment and get the BEST risk adjustment education available for $49. 

Do you need CMEs, CEs or CEUs? We have that too!

All Workshops are approved by the American Medical Association, American Academy of Family Practice, Commission for Case Manager Certification, and the American Academy of Professional Coders.

Register your team (3 or more) today to save 10% on any 2022 Workshops!

Upcoming dates: 

• Saturday, January 22, 2022 https://events.eventzilla.net/e/advanced-risk-management-and-hcc-coding-for-vbp--online-2138830654
• Friday, February 25. 2022 https://events.eventzilla.net/e/advanced-risk-management-and-hcc-coding-for-vbp--online-2138830649
• Friday, March 25, 2022 https://events.eventzilla.net/e/advanced-risk-management-and-hcc-coding-for-vbp--online-2138830648

Learn more / Download the agenda here - www.erm365.org/events

Workshops typically sell out 2 weeks or more before the event. 

Don't wait - register your team today!!

Let's Talk About Risk

 Approved by the AAPC for 2 CEUs  - $5.99 (on SALE until 3/25/2021 - then $14.99)

Review the Agenda:

Section 1 – Risk Adjustment Basics

This section will cover basic concepts and terminology in the CMS-HCC Model of Risk Adjustment.

• What is an HCC?
• Why are HCCs important?
• How is a risk score calculated?
• What is the value of an HCC?
• What are the most common HCCs?

Section 2 – Rules of the Road

This section will cover ICD-10 Guidelines and other “rules” related to clinical documentation and coding within the CMS-HCC Model of Risk Adjustment.

• When should a diagnosis be coded?
• How often can a diagnosis be coded
• What clinical documentation is needed to support the diagnosis?
• Is it okay to code for resolved conditions?
• Would it be acceptable to code a diagnosis documented as “suspected” in an outpatient setting such as a provider’s office?

Section 3 – HCC Coding

This section will review the most common HCC’s for Medicare enrollees based on MedPAC data.

• What are the twenty most common HCC categories for Medicare enrollees?
• What are the most common ICD-10 codes included in each category?
• How can clinical documentation impact code selection?
• What are common errors leading to inaccurate risk scores?

Section 4 – Tips for Success

This section will cover simple tips that will make a big impact. At the end of this lesson you will be able to work smarter not harder.

• What should be included in the problem list?
• Why does clinical documentation need to clarify active vs. history of?
• What small changes can you start making today that will have a big impact on the accuracy of your risk scores?

 

Who Should Attend? 

• Coders, Billers, and Auditors
• Physicians, NPs and PAs
• Medical Assistants and Front Office

 

Price: $5.99 SALE until 3/25/2021, then $14.99 

• Purchase includes a copy of the presentation and other resources. 
• 180 days of access to course and materials. 

 

On Demand Course Instructions for CEUs:

1. Login or Register for a FREE account with ERM365.
2. Purchase the course.
3. Click on “My Dashboard” and then “My Courses” to access.
4. Download the handouts and other resources.
5. Watch the video.
6. Pass the post quiz.
7. Download CEU Certificate. 

2021 CMS-HCC Coding Books and Tools

 

Is Your Team Risk Ready?

Arm Your Team For Combat This Risk Adjustment Season!

Prepare for Victory...

What will define those who claim victory and those who are defeated in the battle towards value based care? Will it be those organizations with the most money, power and seats at the table? Or will it be those who are nimble, flexible and open to change?

I believe it will be both. As victory will not be defined by the owners and head coaches but instead by how the players execute on the field. It will be the game time decisions that matter most. A quarterback who can read the defense and adjust accordingly will provide far greater value to the offense than the most athletic quarterback who misses the blitz every time.

Perhaps Napoleon said it best, "Battles are won by the power of the mind." For in a game of inches, the winners and losers will be defined by those who can execute in the moments that matter most. Prepare your team for victory with information at the point of care!

Learn more / order here - https://erm.ecwid.com/

Medicare Risk Adjustment Operations

 

APPROVED by the AAPC for 5 CEUs

Course Overview

Medicare Advantage (MA) is one of the fastest-growing and most complex health plan lines of business representing significant growth opportunities for payers. Launching and/or managing a successful MA market requires careful, strategic planning to meet requirements, ensure compliance, and maximize the program benefits for your organization.

Success in this market will depend on success in each of the following essential areas:

• Value-based contracting
• Clinical documentation and coding
• Delivering high quality care
• Managing utilization

This course will touch on all four essential areas of MRA Operations.

Learn more or Register here

Review the Agenda below:

Risk Adjustment Operations

• Medicare Risk Adjustment Overview
• History of Medicare Risk Adjustment
• Key Concepts and Terms
• Risk Adjustment Data
• Risk Adjustment Process
• Risk Adjustment Data Validation

CMS-HCC Risk Models

• PY 2020 CMS HCC Risk Adjustment Model
• PY 2021 CMS HCC Risk Adjustment Model
• PY 2022 CMS HCC Risk Adjustment Model

Calculating Risk Scores and Payments

• General Payment Rules
• Data Submissions and Payments
• PY 2020 Risk Score Calculations
• PY 2020 CMS-HCC Payment Calculation Example
• PY 2021 Risk Score Calculations
• PY 2021 CMS-HCC Payment Calculation Example

Optimizing RA Operations

• Network Adequacy Guidance
• Medicare Star Ratings
• Growth and Retention
• Reports and Resources

Visit www.ERM365.org to see more courses. 

Save 30% on all 2020 HCC Tools

 

USE this code: FLASH to save 30% on all HCC Coding Tools!!

Prepare for Victory...

What will define those who claim victory and those who are defeated in the battle towards value based care? Will it be those organizations with the most money, power and seats at the table? Or will it be those who are nimble, flexible and open to change?

I believe it will be both. As victory will not be defined by the owners and head coaches but instead by how the players execute on the field. It will be the game time decisions that matter most. A quarterback who can read the defense and adjust accordingly will provide far greater value to the offense than the most athletic quarterback who misses the blitz every time.

Perhaps Napoleon said it best, "Battles are won by the power of the mind." For in a game of inches, the winners and losers will be defined by those who can execute in the moments that matter most. 

Prepare your team for victory with information at the point of care!

Visit the store to take advantage of the FLASH Sale

 - Remember to use the code "FLASH" to save 30%

Do you like FREE stuff? Register now  so you don't miss out. 

Read the latest post: 6 Reasons Your Risk are Inaccurate

Download the 2021 ICD-10 Updates 

Download the 2021 CMS-HCC Mappings and Software

Learn and earn FREE CEUs from the AAPC

ERM Consulting has developed the industries best training for players on the frontline. Approved by AMA, AAFP and AAPC.

Save 50% on ALL Workshops and Coding Tools

Are you looking for the best education available in risk adjustment, value-based payments and/or CDI?

Good News - You have found it!

Join us for a day of risk adjustment, catch up with colleagues over lunch, and get the best tools in the industry for FREE!

Do you need CMEs or CEUs? We have that too!

All Workshops are approved by the American Medical Association, American Academy of Family Practice and the American Academy of Professional Coders.

Register your team ( 3 or more) today to save 10% on any 2020 Workshop!

Take advantage of Early Bird pricing and Save $100!

Overview:

• Vast changes are coming to the way we purchase healthcare.
• What should your team be doing now to be successful in the world of value-based payments? 
• How do HCCs impact benchmarks and quality scores?
• Review the CMS-HCC Model V24 for risk adjustment in 2020 and 2021. 
• Discuss the importance of managing HCCs year over year. What resources are available from CMS to help? 
• Take a deep dive into the 20 most common HCCs per Medpac data. 
• Common GAPS in claims and encounter data that lead to inaccurate risk scores. 

Download the Agenda Here

Who Should Attend?

-Providers - MDs, DOs, PAs, and NPs

-Medical Directors - Medicare Advantage, ACOs, CPC+ and Medicaid

-Hospitals and Academic Medical Centers

-Medical Coders, Billers and CDI Specialists

-Executive Leaders, Administrators, Directors and Managers

-MSO and IPA Teams

-Rural Health Centers, FQHCs and Community Health Centers

-Health Alliance Members and Medical Society Members

-Medicare, Medicare Advantage, Medicaid and Commercial Plans

  

Each Attendee will Receive ($130):

 - Color copy of the presentation

 - CME from AAFP and AMA

 - CEU from AAPC

REGISTER for a WORKSHOP and Save 50%

To SPONSOR an EVENT

Please email Kameron Gifford

Early Bird Pricing and Group Discounts

Register NOW to save $100 with Early Bird Pricing!

Bring the WHOLE TEAM!

 Register 3 and save 10% on your order!

Order HCC Coding Tools for your Team and Save 50% 

Is Your Team Risk Ready?

Arm Your Team For Combat This Risk Adjustment Season!

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2020 CMS-HCC Quick Coder 2020 CMS-HCC Coding Cards - 12 Pack 2020 CMS ICD-10 to HCC Mappings 2020 Medicare Coding Essentials Visit ERM365 or ERM Consulting to learn more.