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. This article delves into the importance of compliance in healthcare, the role of Annova’s Compliance Team, and how we ensure the alignment of documentation and coding to maintain revenue integrity.
CMS: Beyond the Surface of RADV Audits
While RADV (Risk Adjustment Data Validation) audits may seem centered on High-Risk Conditions (HCC), Annova’s Compliance Team approaches it with a broader perspective. The Centers for Medicare & Medicaid Services (CMS) aim to steer payors and providers towards value-based care, emphasizing the crucial role of accurate documentation. For instance, a generic “Breast cancer” entry is not sufficient; a comprehensive one considering hormonal chemo options, monitoring benefits versus risks, and addressing osteopenia and fall history is needed. CMS advocates for a holistic patient management approach, transcending mere risk scoring and documentation concerns.
The Importance of Comprehensive Documentation
Accurate and thorough documentation ensures that patient conditions are properly reflected in their records. This not only aids in better patient care but also aligns with CMS’s goals of value-based care. By focusing on detailed documentation, healthcare providers can avoid discrepancies that might arise during RADV audits, thereby safeguarding their revenue integrity.
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.
Ensuring Accurate Risk Score Calculation
To prevent RADV rejections, it is crucial that payors provide clear and precise guidelines to coding vendors. Annova works closely with payors to ensure that these guidelines are comprehensive and up-to-date. By doing so, we help minimize errors and discrepancies, thus protecting the financial stability of healthcare organizations.
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.
Prioritizing Accurate Coding
Accurate coding is the cornerstone of revenue integrity. By focusing on the specifics of each condition and ensuring that documentation is precise and detailed, Annova helps healthcare providers maintain compliance and avoid costly mistakes. Our compliance team is dedicated to training and supporting coding teams to achieve this level of accuracy.
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.
Strengthening the Audit Process
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.
Comprehensive Training and Support
Training and education are pivotal in maintaining compliance. Annova provides extensive training programs to ensure that coding teams are well-versed in the latest guidelines and best practices. This ongoing education helps teams stay ahead of regulatory changes and maintain high standards of accuracy and compliance.
Annova’s Expertise in Healthcare Compliance
The Compliance team at Annova approaches projects from three key perspectives: RADV, Payor’s standpoint, and Vendor’s viewpoint.
CMS Perspective
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.
Payor Perspective
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.
Vendor Perspective
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.
Conclusion: Navigating Compliance with Annova Solutions
In the ever-evolving landscape of healthcare, maintaining compliance and revenue integrity is paramount. Annova Solutions stands as a beacon of excellence, providing comprehensive compliance services that ensure accurate documentation and coding. By focusing on training, precision, and proactive solutions, we help healthcare providers navigate the complexities of compliance regulations and safeguard their revenue integrity.
For more information on how Annova Solutions can support your organization in achieving compliance excellence and revenue integrity, contact us today.