Empirical Risk Management
Empirical Risk Management

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Empirical Risk Management

Phone: 772-210-2823

Fax: 772-210-2824


Kameron Gifford, CPC



Todd Gifford, MBA


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The Empirical Advantage

The Solution to Risk Adjustment: A Coder’s Perspective


By Kameron Gifford, CPC


Over the last twelve years, I have worked with physicians to develop efficient billing practices, implement value added processes and improve the entire experience of care for their patients. What can this knowledge contribute to developing compliant, engaging and transparent risk adjustment programs? What can health plans learn from expert practice managers?

Use a Whole System Approach

In medicine, continuity of care can mean the difference between a positive and a negative outcome. We know that fragmented systems don’t work. So why has this become the standard for Medicare Advantage plans? Initial Health Risk assessments are outsourced to midlevel providers that perform a “home based” assessment or perhaps the patient is instructed to visit a website or to call an 800 number.  Then a few months later another company is contracted to “retrieve” medical records from the PCP who then forwards those records to a coder to code any “missing diagnoses”. This does not add any value for the patient. What will?

When patients enroll in a managed Medicare plan they are assigned (or pick) a PCP. This is who should be doing the initial health assessments. CMS encourages FFS providers to perform this type of exam by reimbursing the “Welcome to Medicare” exam with no cost share to the patient. If this is the “standard of care” for some beneficiaries, why not all?

Coding comes from documentation and therefore it is impossible to improve our coding without first improving our documentation. Knowing this, retrospective audits should be used as a tool for identifying deficiencies and a foundation from which specific educational programs can be built to support individual needs and learning styles.

Educate Everyone

In 2011, I began educating medical professionals in compliant HCC Coding and Documentation.  My mission was to teach the fundamental purpose and principles behind the methodology. Doctors are trained to take an enormous amount of information and condense all of this into a progress note. This abbreviated summary of events is then interpreted into ICD-9 and CPT Codes (which may or may not risk adjust) which will determine the amount of reimbursement for that particular service.

Currently plans are trying to interject change at the end of a process. Instead, by educating physicians, nurses, coders, administrators, medical assistants, and receptionists change can be implemented at the initial point of contact. If the medical assistant and nurse understand quality measures they will be able to accurately audit the chart before the physician ever walks in. Flags can be raised for patients who have not had their mammogram or who didn’t turn in their hemmoccult cards. Physicians who understand the 10 guiding principles of HCC will document to a higher a degree of specificity and use linking words. A coder with training in HCC Coding will know that you must use a buddy code when coding manifestations. This knowledge allows the coder to query the physician immediately when the case is still fresh on their mind.  The ability to audit in “real time” expedites the process of changing one’s behavior and the physician’s ability to adapt under these circumstances are amazing. The end result is a complete an accurate medical record which does add value to the patient.

Return on Investment

Education empowers. One of the greatest dilemmas in managed care is how to get physician buy in? By providing quality educational opportunities to not only physicians but to their office staff as well you will position yourself as a blessing instead of a burden. In the current environment of greater oversight, tighter regulations and changing reimbursement patterns providing something as simple as education builds relationships.

Empirical Risk Management tested this philosophy and the return on investment was incredible. 300 to 1. But, the greatest achievement of all was seeing the hunger for knowledge and the positive impact on human life that was reflected in patient centered whole system change.


For more information please visit our website: www.ermconsultinginc.com or by email: kgifford@ermconsultinginc.com

The Real Cost of Education, Auditing and Patient Engagement: $5 PMPM


Republican, Democrat or Independent; Provider or Payor, It doesn’t matter what side of the line you fall on – we can all agree on one thing – Healthcare Reform is as necessary as it is Inevitable. We must align ourselves for the paradigm shift that lies ahead. We can’t continue to repeat the same actions over and over again with the expectation of different results? That, by definition, is insanity.

I recently wrote an article, “Mission Critical, Target Missed: $34.1 Billion in Overpayments to MA Plans in 2012” in which I referenced a recent study that found MA plans were (on average) overpaid $2,600 per beneficiary last year. If we break that down month over month we are looking at approximately $200 per month per enrollee. What did MA plans spend that money on in 2012?

How did their enrollee’s experience of care compare to their neighbors who elected to stick with traditional Medicare? And what about the providers who took care of these patients? How did their experience of providing care to MA members compare to those patients with traditional Medicare?

It might surprise you that the answer to that question would fluctuate greatly depending on who you asked, where they lived, what type of care they needed (or provided) and what plan they were enrolled with (or contracted with) last year.

According to the Kaiser Foundation, Medicare Advantage enrollment grew by 10% in 2012, exceeding 13 million enrollees or 27% of the total Medicare population. Of those 13.1 million, only 26% of all Medicare Advantage enrollees were covered by plans that were rated as above average or excellent, and 575,000 enrollees, about 9% were in plans that were “underperforming” and received less than 3 stars.

This is our solution? A solution that is plagued with complex reimbursement systems and unsustainable costs? One in which the access to care has been severely restricted all in the name of cost reduction? A system in which patients with insurance are unable to access the care they need and as a result do not get cost saving, preventive services. A solution that is only providing average care to the majority of our seniors?

We know that the cost of care is directly proportionate to the value it provides, and to be effective, that value must be meaningful to the patient.

So how much money was invested in 2012 by Medicare Advantage plans to close traditional gaps, improve access to care and educate patients? What incentives were paid to primary care doctors who went over and above the traditional “standard of care” to coordinate, monitor, and deliver care even during those critical periods of transitions? What about on patient outreach? Who is calling the member who hasn’t reached out to their PCP after enrolling? Or, are we only reaching out to those that are over-utilizing services?

Education is the only answer to a sustainable system.

What training is mandated for HCC Coders? Why aren’t physicians being taught the underlying principles of risk adjustment instead of being asked to assign specific ICD-9 codes to their MA members? Where is the transparency that Obamacare was intended to provide?

What if the answer to our healthcare crisis isn’t in the millions of medical records we are auditing and re-auditing? What if the answer isn’t in the “missing diagnosis” codes or the “monetary penalties such as recoupments”?

But, instead in the investment of education for patients, providers and office staff? What if the answer was creating more flexibility in the delivery of care or strengthening communities to bring that sense of responsibility into our neighborhoods? What if we took the money invested in prosecuting and defending waste, fraud and abuse and redirecting it into improving access and developing mobile platforms to meet the needs of patients?

Empirical Risk Management was able to create this personalized, comprehensive, integrated care in our recent pilot program. The cost of the program was less than $5 per member per month, and then value it created can be seen in the outcomes.

If we can improve what we are currently doing for as little as $5 per member per month, where is the other $195 being spent?

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