Karen Weed, VP of Value-Based Solutions at RCxRules, attended the RISE National 2022 annual conference and shares her takeaways in this blog post.
A few weeks ago, I joined more than 1,600 participants in Nashville to discuss all things Medicare Advantage and explore how to best move forward in the ever-evolving landscape. From regulatory and compliance updates to risk adjustment, quality, HEDIS®, Star ratings, member experience, social determinants of health (SDoH), the latest technology advancements, and payer/provider collaboration, we covered a huge variety of topics.
While there were many learnings and takeaways from this event, the key point I walked away with was confirmation that Medicare Advantage enrollment continues to grow—and that this growth is fueling an increased need for solutions to address HCC capture, quality measures, and identification of SDoH. These solutions require people, processes, and technology—and finding the right balance of these three elements will be crucial to success.
The past few years have necessitated rapid changes throughout healthcare, and the implications are still resonating—particularly when it comes to HCC capture. As groups move towards ways to assess health outside of the physician office, such as home health visits with health risk assessments (HRAs) or telehealth, they’re facing additional scrutiny from health plans, OIG, and CMS. Groups are under additional pressure to ensure diagnoses are properly documented and have associated care plans or support. Moving forward, groups will need to show that they have processes in place to not only add diagnoses, but also to delete diagnoses. These processes need to be trackable and reportable.
Groups that capture HCCs through an HRA without supporting documentation and a concrete follow-up plan run the risk of audit and deletions. If an HRA takes place, there should be additional documentation associated with any conditions captured—documentation of a follow-up visit with a Primary Care Provider, for example. As care happens outside of the office, groups are responsible for ensuring any data coming in is both accurate and acted upon.
There are also certain HCCs that are more likely to be scrutinized. One example that came up at RISE a few times was the HCC associated with an acute stroke. An acute stroke should only be recorded in a hospital setting, meaning there should be additional documentation that indicates a hospital visit. There should also be indications of follow-up care. HCCs associated with major depression are another example—these codes should not stand alone. There should be other documented indicators of depression, such as medication and follow-up visits.
As HCC capture expands to different programs and technologies, groups will need to be sure to maintain control of the data–which can be done most efficiently and effectively with the use of skilled people, strong compliance processes, and intelligent and reportable technology.
To learn more about how the RCxRules HCC Coding Engine can help your organization ensure accurate claims and improve your processes, set up a meeting today.
