Do you fear having discrepancies due to misinterpretation of compliance regulations by your coding partner which could jeopardize your company’s revenue integrity?
In the intricate world of compliance regulations, misconceptions can cast shadows on revenue integrity, leaving businesses vulnerable to discrepancies. At Annova, we understand the nuances of compliance, recognizing that a misstep could potentially jeopardize the very core of revenue management.
CMS: Beyond the Surface of RADV Audits
While RADV audits may seem centered on High-Risk Conditions (HCC), Annova’s Compliance Team approaches it with a broader perspective. CMS’s aim is to steer payors and providers towards value-based care, emphasizing the crucial role of accurate documentation. Take, for example, the contrast between a generic “Breast cancer” entry and a comprehensive one that considers hormonal chemo options, monitoring benefits versus risks, and addressing osteopenia and fall history. CMS advocates for a holistic patient management approach, transcending mere risk scoring and documentation concerns.
Payors: Aligning Expectations with Documentation
Payors aspire to avoid RADV rejections and retrospective reviews by urging providers to meticulously document risk-adjusted conditions. Despite understanding the risks and the interconnectedness of value-based care and proper documentation, this synergy is not always reflected in guidelines provided to coding vendors. Annova recognizes the need for precision in risk score calculation and strives to bridge this gap, ensuring alignment between payors’ expectations and project guidelines.
Vendors: Shifting Focus to Accuracy
In the vendor landscape, the focus often veers towards administrative details rather than accurately coding risk-adjusted conditions. Annova’s Compliance Team, however, aims to shift this paradigm. Instead of fixating on NPI, place of service, and signature issues, we prioritize accurate coding to the highest specificity. Our approach is rooted in identifying documentation deficiencies and steering clear of errors identified in coding audits, ultimately contributing to a more robust compliance framework.
Solutions: Annova’s Approach to Safeguarding Interests
Navigating Compliance: Annova’s Commitment to Revenue Integrity: Our Compliance Team acts as a proactive force, identifying high-risk coding practices, investigating root causes, and providing solutions. Comprising experienced risk adjustment coders and compliance experts, the team collaborates with clients, payors, and in-house coders. Our primary focus is on creating and updating reference and training documents in alignment with industry changes, RADV findings, and emerging risk adjustment coding trends.
At Annova, we believe in strengthening the audit process by focusing on what truly matters. Our Compliance Team empowers coding teams to interpret project guidelines accurately, fostering a culture of precision and compliance. Together, we navigate the complex landscape of compliance regulations, ensuring revenue integrity and safeguarding the interests of our clients and payors.
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The Compliance team at Annova approaches projects from three key perspectives: RADV, Payor’s standpoint, and Vendor’s viewpoint.
CMS
While it may seem that RADV audits are focused on HCC conditions which have often been associated with inappropriate high-risk scores, inadequate documentation and fraud, there is a broader focus. CMS aims to drive payors and providers toward value-based care, emphasizing its reflection in documentation. For instance, comparing the documentation of “Breast cancer followed up by the oncologist” to “Breast Cancer, following up with oncology for hormonal chemo options, monitoring benefit vs risk due to osteopenia and history of falls” reveals the latter’s holistic patient management approach. In contrast, the former raises doubts about the actual presence of cancer. CMS strives for patient management beyond risk scoring and documentation concerns.
Payors
Payors want to prevent RADV rejections and costly retrospective reviews by expecting providers to accurately document risk-adjusted conditions to facilitate precise risk score calculation. Even though payors understand the risk of RADV and the interconnectedness of value-based care and proper documentation, this synergy is not consistently reflected in project guidelines provided to coding vendors. Despite the risk of rejections, conditions are often coded without active MEAT and from past headers. High-risk conditions such as cancers, fractures, and CVAs are frequently documented without sufficient active evidence due to outdated or inaccurately interpreted guidelines.
Vendors
Vendors frequently prioritize steering clear of errors identified in coding audits conducted by payors (in-house or third-party auditors). Their attention tends to center on administrative details such as provider NPI, place of service, and signature issues, rather than addressing the broader goal of accurately coding risk-adjusted conditions to the highest specificity and identifying documentation deficiencies.
Solutions
The compliance team identifies high-risk coding practices within teams, investigates the root causes, and provides solutions with the core objective of safeguarding the interests of the Payor.
Annova’s compliance team, consisting of experienced risk adjustment coders and compliance experts, collaborates with Clients/payors, their coding teams and Annova’s in-house coders.
The team’s primary focus is on working with clients on creating and updating reference and training documents in alignment with recent changes, RADV findings, and emerging risk adjustment coding trends.
The team helps strengthen the audit process by focusing on the areas that matter, helps coding teams to interpret the project guidelines and focus on accurate coding.