With upcoming changes under health reform and pressures to gain revenue, healthcare institutions must make risk-adjustment training a must for all stakeholders, according to Joy Ridlehuber, senior clinical training specialist at Fort Worth-based Leprechaun, LLC, which outsources hierarchical condition category (HCC) management solutions for Medicare advantage plans.
"You really must have a training program no matter what type of organization you are," Ridlehuber said at the Opal Events' Medicare Advantage Strategic Business Symposium in Arlington (Va.) on Tuesday. Risk-adjustment training applies to the small practice all the way up to the large institution, she added.
In addition, training shouldn't be isolated to only staff in coding, health information management, or IT; it must be expanded to providers, care management, client services, and vendors, as well. For example, Ridlehuber said, an IT professional might not have a healthcare background, or vice versa.
"Risk adjustment translates to higher reimbursement with more specific documentation," Ridlehuber said. "You don't want to leave money on the table when you need that to care for members," she added.
In addition, Medicare Advantage members will increasingly play a role in reimbursement as they provide feedback for the 5-star quality rating system mandated in 2010. With ICD-10 pressures and EMR transitions coming down the pike, education seems to be an absolute necessity.
Among the key points to include in risk-adjustment training:
- "Every year, CMS wipes the slate clean on Jan. 1," Ridlehuber said. That means, that organizations must submit diagnosis at least once every year for chronic condition patients.
- Documentation must reflect face-to-face visits for claims to be substantiated.
- On every page of documentation, it must have a patient identifier (e.g., name, ID number), date of encounter, valid signature (written or electronic but not stamped), providers' credentials to distinguish (for example, who is a physician versus a nurse practitioner), and date of signature.
- If signatures are electronic, then the documentation must include the proper regulation-approved language surrounding electronic signatures.
- Providers are reimbursed on CPT codes, and Medicare Advantage reimburses on diagnosis codes
Training can take many forms--in the classroom, online, or self-study. The important takeaway is that the training happens, Ridlehuber said.