Empirical Risk Management
Empirical Risk Management

Where to Find Us:

Empirical Risk Management

Phone: 772-210-2823

Fax: 772-210-2824

 

Kameron Gifford, CPC

772-267-9453

 

Todd Gifford, MBA

772-267-8156

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16.04.2022
MRA Alerts and Updates
1 Comments

 

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 - https://erm.ecwid.com/

ORDER TODAY - THESE WILL GO FAST!!

CMS-HCC Coding Cards

https://erm.ecwid.com/2022-CMS-HCC-Coding-Cards-12-Pack-p432478501

You will love these 5x7 HCC Coding Cards!

Updated for 2022 - Version 24

This 14 pack is perfect your next risk adjustment project.

1.Diabetes:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

2.COPD:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

3.Heart Failure:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

4.Major Depressive Disorder:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

5.Malnutrition and Morbid Obesity:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

6.Complications with Internal Devices and Dependence:

•ICD-10 Coding Tips for Complications (side 1) includes RAF

•ICD-10 Coding Tips for Dependency(side 2) includes RAF

7. Infectious Disease:

•ICD-10 CDI / Coding Tips for HIV and Sepsis (side 1) includes RAF

•ICD-10 Coding Tips for Liver Disease (side 2) includes RAF

8. Heart Failure:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

9. Chronic Kidney Disease:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

10. Seizures and Neurological Disorders:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

11. Diseases of the Digestive System:

•ICD-10 ICD-10 Coding Tips (side 1) includes RAF

•ICD-10 ICD-10 Coding Tips (side 2) includes RAF

12. Primary and Secondary Neoplasms:

•ICD-10 ICD-10 Coding Tips (side 1) includes RAF

•ICD-10 ICD-10 Coding Tips (side 2) includes RAF

13. Coagulation Defects:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

14. Disorders of Immunity

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

Post one to your bulletin board, stick one near the EHR or tape it to your workstation!

HCC Coding Cards are made to last all year on thick 16 pt cardstock with a gloss finish.

Order for your team today!

CMS-HCC Quick Coders

https://erm.ecwid.com/2022-CMS-HCC-Quick-Coder-p432456253

Completely updated for 2022 - Version 24

This 42 page guide contains everything you need to calculate a risk score in one place!

Includes of the most common HCC codes in the Medicare (CMS-HCC) model.

This guide was designed for providers, with codes sorted alphabetically rather than by code.

Order one for the entire team today!

Includes:

List of ICD-10 Guidelines270 ICD-10 Codes (Rx and HCCs)Quality CPT II codes for MIPS / MACRAAll CMS-HCC Risk Factors (includes demographic, disease and interaction)Trump ChartLearn more / order here - https://erm.ecwid.com/

02.04.2022
MRA Alerts and Updates
No comments

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/

11.01.2022
MRA Alerts and Updates
No comments

 

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 - https://erm.ecwid.com/

ORDER TODAY - THESE WILL GO FAST!!

CMS-HCC Coding Cards

You will love these 5x7 HCC Coding Cards!

Updated for 2022 - Version 24

This 14 pack is perfect your next risk adjustment project.

1.Diabetes:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

2.COPD:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

3.Heart Failure:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

4.Major Depressive Disorder:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

5.Malnutrition and Morbid Obesity:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

6.Complications with Internal Devices and Dependence:

•ICD-10 Coding Tips for Complications (side 1) includes RAF

•ICD-10 Coding Tips for Dependency(side 2) includes RAF

7. Infectious Disease:

•ICD-10 CDI / Coding Tips for HIV and Sepsis (side 1) includes RAF

•ICD-10 Coding Tips for Liver Disease (side 2) includes RAF

8. Heart Failure:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

9. Chronic Kidney Disease:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

10. Seizures and Neurological Disorders:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

11. Diseases of the Digestive System:

•ICD-10 ICD-10 Coding Tips (side 1) includes RAF

•ICD-10 ICD-10 Coding Tips (side 2) includes RAF

12. Primary and Secondary Neoplasms:

•ICD-10 ICD-10 Coding Tips (side 1) includes RAF

•ICD-10 ICD-10 Coding Tips (side 2) includes RAF

13. Coagulation Defects:

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

14. Disorders of Immunity

•ICD-10 Coding Tips (side 1) includes RAF

•Clinical Documentation Tips (side 2) includes RAF

Post one to your bulletin board, stick one near the EHR or tape it to your workstation!

HCC Coding Cards are made to last all year on thick 16 pt cardstock with a gloss finish.

Order for your team today!

CMS-HCC Quick Coders

Completely updated for 2022 - Version 24

This 42 page guide contains everything you need to calculate a risk score in one place!

Includes of the most common HCC codes in the Medicare (CMS-HCC) model.

This guide was designed for providers, with codes sorted alphabetically rather than by code.

Order one for the entire team today!

Includes:

List of ICD-10 Guidelines270 ICD-10 Codes (Rx and HCCs)Quality CPT II codes for MIPS / MACRAAll CMS-HCC Risk Factors (includes demographic, disease and interaction)Trump ChartLearn more / order here - https://erm.ecwid.com/

13.12.2021
MRA Alerts and Updates
No comments

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)

13.12.2021
MRA Alerts and Updates
No comments

 

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-2138830654Friday, February 25. 2022 https://events.eventzilla.net/e/advanced-risk-management-and-hcc-coding-for-vbp--online-2138830649Friday, March 25, 2022 https://events.eventzilla.net/e/advanced-risk-management-and-hcc-coding-for-vbp--online-2138830648Learn more / Download the agenda here - www.erm365.org/eventsWorkshops typically sell out 2 weeks or more before the event. Don't wait - register your team today!!

02.06.2021
MRA Alerts and Updates
5 Comments

Are you looking for the best risk adjustment education available? If so, GREAT NEWS, you found it! Join us virtually for a day of risk adjustment, CDI and HCC coding! NEW DATES added below:

June 25, 2021 – Register for tickets here https://events.eventzilla.net/e/advanced-risk-management-and-hcc-workshop--online-2138808989July 30, 2021 – Register for tickets here https://events.eventzilla.net/e/advanced-risk-management-and-hcc-workshop--online-2138808991August 27, 2021 – Register for tickets here https://events.eventzilla.net/e/advanced-risk-management-and-hcc-workshop--online-2138808990September 24, 2021 – Register for tickets here https://events.eventzilla.net/e/advanced-risk-management-and-hcc-workshop--online-2138808986

APROVED by:  AMA, AAFP, AAPC and CCMC - Earn 7.0 CEUs, 6 CMEs and/or 5.5 CEs. - $49 per Attendee

Register your team today and save 10% with group discounts!

LEARN MORE at www.ERM365.org/events  

01.05.2021
MRA Alerts and Updates
10 Comments

Are you looking for the best risk adjustment education available? If so, GREAT NEWS, you found it! Join us virtually for a day of risk adjustment, CDI and HCC coding! NEW DATES added below:

June 25, 2021 – Register for tickets here https://events.eventzilla.net/e/advanced-risk-management-and-hcc-workshop--online-2138808989July 30, 2021 – Register for tickets here https://events.eventzilla.net/e/advanced-risk-management-and-hcc-workshop--online-2138808991August 27, 2021 – Register for tickets here https://events.eventzilla.net/e/advanced-risk-management-and-hcc-workshop--online-2138808990September 24, 2021 – Register for tickets here https://events.eventzilla.net/e/advanced-risk-management-and-hcc-workshop--online-2138808986

APROVED by:  AMA, AAFP, AAPC and CCMC - Earn 7.0 CEUs, 6 CMEs and/or 5.5 CEs. - $49 per Attendee

Register your team today and save 10% with group discounts!

LEARN MORE at www.ERM365.org/events  

Why OIG Did This Audit

Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services (CMS) makes monthly payments to MA organizations according to a system of risk adjustment that depends on the health status of each enrollee. Accordingly, MA organizations are paid more for providing benefits to enrollees with diagnoses associated with more intensive use of health care resources than to healthier enrollees who would be expected to require fewer health care resources.

To determine the health status of enrollees, CMS relies on MA organizations to collect diagnosis codes from their providers and submit these codes to CMS. CMS then maps certain diagnosis codes, on the basis of similar clinical characteristics and severity and cost implications, into Hierarchical Condition Categories (HCCs). CMS makes higher payments for enrollees who receive diagnoses that map to HCCs.

For this audit, we reviewed one of the contracts that Humana, Inc., has with CMS with respect to the diagnosis codes that Humana submitted to CMS. Our objective was to determine whether Humana submitted diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements.

How OIG Did This Audit

We selected a sample of 200 enrollees with at least 1 diagnosis code that mapped to an HCC for 2015. Humana provided medical records as support for 1,525 HCCs associated with the 200 enrollees. We used an independent medical review contractor to determine whether the diagnosis codes complied with Federal requirements.

What OIG Found

Humana did not submit some diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements. First, although most of the diagnosis codes that Humana submitted were supported in the medical records and therefore validated 1,322 of the 1,525 sampled enrollees' HCCs, the remaining 203 HCCs were not validated and resulted in overpayments. These 203 unvalidated HCCs included 20 HCCs for which we identified 22 other, replacement HCCs for more and less severe manifestations of the diseases. Second, there were an additional 15 HCCs for which the medical records supported diagnosis codes that Humana should have submitted to CMS but did not.

Thus, the risk scores for the 200 sampled enrollees should not have been based on the 1,525 HCCs. Rather, the risk scores should have been based on 1,359 HCCs (1,322 validated HCCs + 22 other HCCs + 15 additional HCCs). As a result, we estimated that Humana received at least $197.7 million in net overpayments for 2015. These errors occurred because Humana's policies and procedures to prevent, detect, and correct noncompliance with CMS's program requirements, as mandated by Federal regulations, were not always effective.

What OIG Recommends and Humana's Comments

We recommend 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.

Humana disagreed with our findings and with both of our recommendations. Humana provided additional medical record documentation which, Humana said, substantiated specific HCCs. Humana also questioned our audit and statistical sampling methodologies and said that our report reflected misunderstandings of legal and regulatory requirements underlying the MA program. After reviewing Humana's comments and the additional information that it provided, we revised the number of unvalidated HCCs for this final report. We followed a reasonable audit methodology, properly executed our sampling methodology, and correctly applied applicable Federal requirements underlying the MA program. We revised the amount in our first recommendation from $263.1 million (in our draft report) to $197.7 million but made no change to our second recommendation.

Complete Report available here. 

 

02.04.2021
MRA Alerts and Updates
5 Comments

 

Medicare Risk Adjustment Operations

On-Demand 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 contractingClinical documentation and codingDelivering high quality careManaging utilization

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

APPROVED by the AAPC for 5 CEUs - $9.99 until 4/9/2021 and then $19.99

Register here https://erm365.org/courses/medicare-risk-adjustment-operations/

Learn more about ERM365
21.03.2021
MRA Alerts and Updates
3 Comments

 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 codedWhat 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 AuditorsPhysicians, NPs and PAsMedical 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:

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