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How Retrospective Risk Adjustment Optimizes Reimbursement

healthcare reimbursement

Healthcare institutions rely on revenue cycle management (RCM) to optimize and streamline healthcare service payments. With reimbursement processes becoming increasingly complex and intricate, risk adjustment (particularly the retrospective kind) ensures the financial sustainability of the healthcare provider ecosystem. In the medical coding and billing system, retrospective risk adjustment is critical for managing risk. Let’s explore its role in maximizing reimbursement.

Risk Adjustment Coding Review Types

In Risk adjustment coding, the Hierarchical Condition Category (HCC) model is designed to forecast future spending for Medicare beneficiaries using a forward-looking risk-adjustment approach. Within this model, ICD-10-CM procedure codes are grouped into disease categories known as HCCs. These HCCs include diagnosis codes with clinical characteristics or similar cost implications.

There are three primary review processes for HCC: Prospective Review – prepares for future patient encounters; Concurrent Review – real-time analysis of patients’ codes; and Retrospective Review – analysis of prior patients’ code accuracy.

Prospective Review

The prospective coding review process, headed by certified risk coders, preps physicians for forthcoming patient interactions. Coders analyze the patient’s HCC code history, medical records, and even out-of-network claims data to understand the patient’s clinical data comprehensively. In doing so, they pinpoint potentially missed HCC conditions and facilitate accurate diagnosis coding. Physicians are informed in advance to address these identified HCC opportunities, typically through EHR updates or pre-appointment briefings.

Concurrent Review

In the concurrent coding review process, coders examine EHR notes and HCC codes in real-time, using existing EHR and RCM technologies, before claim submission to payers. This ensures that the physician’s comprehensive clinical documentation aligns with the selected ICD-10 code. The process validates the accurate translation of a physician’s efforts into correct HCC codes and reduces the necessity for retrospective reviews by initially providing payers with accurate codes. This method is most effective when combined with initiatives like prospective review and physician training.

Retrospective Review

Retrospective risk adjustment ensures healthcare organizations accurate reimbursements by examining past claims for provided services. Retrospective coding reviews, conducted after care delivery and claim submission, frequently identify HCC codes that weren’t unreported despite being supported by medical records or were inaccurately submitted without meeting documentation criteria. These evaluations tend to uncover repeated and persistent clinical documentation issues and necessitate a subsequent step to rectify and resend the accurate HCC codes to the payer.

While this method pairs well with Medicare Advantage programs through the Alternate Submission Method (ASM), its integration becomes challenging in ACOs and CPC+ programs due to the complexity of submitting retrospective coding adjustments.

The role of retrospective risk adjustment is crucial in identifying and filling gaps in coding to ensure healthcare providers receive accurate compensation for their services. Given the intricacies of medical billing and coding, errors or omissions are bound to occur. These discrepancies can translate into substantial financial losses or potential compliance issues if not promptly and adequately addressed.

Advantages of Retrospective Risk Adjustment

Retrospective risk adjustment is crucial in the healthcare revenue cycle, ensuring providers receive appropriate compensation while maintaining compliance and efficiency. This method has numerous advantages contributing significantly to the healthcare provider coding and billing ecosystem.

Ensures Accurate Compensation: Healthcare institutions can ensure accurate reimbursement for services provided by reviewing past claims. Without this review, providers may miss out on entitled revenue.

Enhances Compliance: Regular retrospective reviews can aid healthcare institutions in staying compliant. Institutions can avoid potential legal complications and penalties by identifying and correcting any coding errors or omissions.

Optimizes Future Claims Processes: Retrospective risk adjustment not only corrects past mistakes but also optimizes future claims for Prospective Risk Adjustments. Healthcare providers can improve coding practices by understanding where mistakes are made, making the entire RCM process more efficient.

Offers Continuous Feedback: Retrospective reviews provide continuous feedback to improve the coding process, ensuring that coders are always at the top of their game and up to date with the latest coding best practices.

Challenges and Solutions of Retrospective Risk Adjustment

Although retrospective risk adjustment provides many benefits, it presents some challenges. While it is a natural fit for programs such as Medicare Advantage through the ASM, it can be challenging to incorporate it into specific programs.

However, many of these challenges can be mitigated by:

Investing in Advanced RCM Technology: Advanced RCM technology can automate many of the processes involved in retrospective risk adjustment, making it more efficient and less prone to human error while reducing the costs and stress of dedicated billing staff.

Collaborating with a Healthcare Coding Company: Partnering with a specialized healthcare coding company can also benefit healthcare providers and organizations. Retrospective risk adjustment can be complex, but reputable companies have the expertise and resources to ensure optimal outcomes.

GeBBS’ iCRA-enabled Risk Adjustment Services

GeBBS Healthcare Solutions uses iCRA-enabled Risk Adjustment Services to streamline risk adjustment and healthcare processes efficiently. The iCRA chart acquisition platform combines cutting-edge iCode workflow solutions with provider-sensitive processes.

GeBBS portals prioritize data security and privacy while offering user-friendly features that are HIPAA-compliant. The software offers drag-and-drop functionality and an EMR CCD data exchange feature for seamless data transfer. To ensure proficient handling of patient care and data management, the service provides onsite retrieval options in addition to traditional methods such as fax and mail.

GeBBS’ iCRA services provide many benefits, including reducing provider abrasion and creating a smoother, frictionless experience. The secure provider portal they have integrated is proof of their dedication to data security. The platform prioritizes efficiency and has successfully reduced chart retrieval expenses by 30%.

Additionally, the iCRA platform’s real-time monitoring allows users to track chart retrieval status and exception distribution, providing healthcare providers unparalleled control over their projects. The provider portal is highly efficient, with 98% accurate data capture on the first attempt and 40% of users utilizing it for uploads. The addition of scheduling onsite visits ensures GeBBS’ digital expertise is complemented by tangible interaction, solidifying its position as a leader in the field.

Retrospective risk adjustment ensures healthcare providers receive appropriate compensation for their healthcare services by identifying and correcting any past coding errors and discrepancies. As healthcare institutions encounter billing and coding challenges, embracing retrospective risk adjustment methods, supplemented by expert offshore medical coding solutions from reputable industry leaders like GeBBS, ensures accurate reimbursements and bolsters their overall financial health.

Contact us at gebbs.com today to learn how your organization can benefit from expert risk adjustment coding to improve code accuracy and increase patient satisfaction.

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