Medicare Risk Adjustment (MRA) is one of the keystones of successful managed care and accountable care practices, organizations, and associations. While a successful program can pitchfork an organization into immense success, it can also open it to significant vulnerabilities, deficiencies, and risks.
The challenge is multi-factorial and any attempt to create an MRA compliant organization must be multi-level, multi-departmental, consistent, continuous, systematic, and methodical.
These are some of my reflections about how to develop an integrated approach towards MRA compliance:
- Compliance goes together with MRA. Recently, I heard some providers insist that certain diseases should not be documented because they do not trigger HCC (Hierarchical Condition Category) codes. These are statements that leave one flabbergasted. MRA follows compliance and not vice versa. If you and your patient are dealing with a diagnosis, then whether or not it “triggers” payment is irrelevant. Say what you see and treat all conditions that threaten a patient’s well-being. First do what is compliant and diagnoses will derive from that. That goes also for the deletion of codes that have been incorrectly documented or billed as well. If you make an error, correct it.
- MRA compliance is an organizational and team-based initiative. It does not belong to one department, specialty, or silo. The leadership needs to stand behind it and consistently support, no matter how intractable the challenges. In almost 15 years of trying to create a platform where compliance is a natural way of being and part of our culture, we still find pockets of resistance and obtuseness. Then, everyone must work as a team and address the issues. MRA compliance needs to be constantly tweaked and adapted to situations by the team and constant communication and feedback are critical.
- Relationship management is a sine qua non. I have personally visited about 300 providers in the last 4 months and talked to them, taken their feedback, reviewed their numbers, strengths, and opportunities. In this process, I have gained valuable insights into their offices, their challenges, and about our processes. This cannot be a top-down approach, but providers and their staff must be closely involved throughout.
- No number is the right target. The target should be compliant MRA, not an arbitrary score. Although one can look at patterns of billing, see opportunities, and try to address them.
- Correct and compliant incentivization is key. If providers are still being paid fee-for-service in a fee-for-value environment, they will have no initiative to spend extra time to review past medical history or prior records, and there will be a hidden conflict always no matter how hard one tries. Bonuses for quality, compliance, patient satisfaction, net promoter scores, patient safety, wait-times, etc. can and should be considered and implemented.
- A knowledge-based approach and communication where constant research, learning, confirmation from references and sources, and dialog with subject matter experts is ongoing will keep the MRA compliance program up-to-date and relevant and errors will be minimized. A learning organization is the best entity to run and manage MRA initiatives.
- Education of providers, staff, leadership, vendors, and administration is the secret. The training and acculturation should be intensive, granular, repetitive, and preferably entertaining. A multi-media approach may be taken, bolstered by face-to-face contacts, group sessions, reminders, and shared learning, especially what we learn from mistakes. Social media is a powerful tool as is e-mail. The written word, along with audio and visual presentations, quarterly sessions, mobile apps, emails, and gaming can be deployed to provide learning tips, pearls, and reminders. The goal is to change habits among professionals and adults but once accomplished, the rest becomes easier.
- Operational synergy among the various departments, including clinical, information technology, finance, compliance, and risk management along with quality and utilization, enhances the program several-fold. Operations would involve targeted education for blind spots among providers or staff, integrating the work of Clinical Documentation Instructors (CDIs) with billers, coders, and auditors ensuring that data is constantly shared and is authentic.
- Technology can align workflows so that the documentation by the doctor is transferred into ICD (International Classification of Diseases) codes appropriately and then billed to the clearinghouse, then transmitted to the insurance or Health Maintenance Organization (HMO) and eventually to CMS (Center for Medicare and Medicaid Services). Without real-time data, operations cannot be successful, and interventions are not effective. A platform that integrates Electronic Medical Records and CCDs, CDI work, billing and coding, and auditing, along with MRA calculators, validation tools, education learning management systems, and EDPS and RAPS giving a portal to providers and offices, tracking each patient, code by code, would create a right foundation for analytics, data management, artificial intelligence, natural language processing and generation and robotic process automation.
- Ascending the value chain is vital for any IPA or practice as they are the producers of data. They need to consume it too in a manner that they can confirm that the data is indeed being transmitted to CMS and they are being compensated for all the diseases documented and that the HMOs are on their toes.
- Correct and compliant documentation is the most important aspect of MRA. If the physician does not document conditions properly, if the note is not adherent to CMS recommendations, if there is cloning, or the conditions not adequately addressed and just strung in a list of diagnoses, then nothing much can be done thereafter. But, if all the patients are brought in, diagnoses validated, gaps closed, chronic conditions brought forward, suspect conditions addressed, then the rest is a matter of improved management of data and people. The CDIs are an integral factor in ensuring that this is accomplished. I usually spend an hour with the whole team of our CDIs, who work remotely, twice a week to ensure that they are compliant, precise, focused, valid, and motivated.
- Revenue Cycle Management, though part of operations, merits a separate consideration since ensuring more than 4 HCC codes can be transmitted, that the coders and billers are trained and certified and audited themselves, that rejections are worked along with receipt of claims by CMS and their acceptance can make the crucial difference between mediocrity and excellence.
Suffice it to say that MRA compliance is not for sissies. But if addressed in an organized and deliberate manner, it can be the source of greatest strength to any entity that takes managed care or accountable care.