Fixing Medicare Advantage Payments

This article looks at the problem from the other side. Here, we adopt a position sympathetic to the hurdles facing Medicare Advantage plans and look at how they are trying to improve the quality of data. A bit of cynicism is deserved here. Consultants who offer services to healthcare providers often cite “improving the quality of diagnoses” as a code phrase for “extracting the maximum payment you can for a given patient.” I talked recently to Meleah Bridgeford, senior director of risk adjustment analytics at Episource, about how their analytics and billing solution can improve the quality of submissions and payments at Medicare Advantage plans. She says that quality has to be balanced; you need a system that honestly counts both missing diagnosis codes that can increase CMS payments (“adds”) and codes that don’t meet standards and require the plan to remit payments back to CMS (“deletes”). Figure 1 shows a typical dashboard from Episource. Figure 1: Dashboard showing a breakdown by year Chart reviews are independent examinations of patients’ clinical records. They’re valuable for many reasons. CMS requires chart reviews to catch overpayments. But Medicare Advantage plans do their own chart reviews to improve the quality of care as well as to avoid penalties from CMS. Reasons for chart reviews include: Finding clinical interventions that weren’t correctly billed, or perhaps weren’t billed at all. If...
Source: EMR and HIPAA - Category: Information Technology Authors: Tags: Administration Analytics/Big Data Health IT Company Healthcare IT Regulations Revenue Cycle Management CMS Episource Healthcare Billing Medical Billing medical coding Medicare Medicare Advantage Medicare Audits Upcoding Source Type: blogs