With many healthcare organizations transitioning to value-based care (VBC) programs, ensuring accurate hierarchical condition category (HCC) documentation that leads to accurate risk adjustment factor (RAF) scores in risk adjustment is challenging.
The objective of a risk adjustment program is to ensure accurate funding to health plans for the expense of enrollees, whilst discouraging incentives for health plans to selectively enroll healthier members. It is designed to ensure health plans focus on the quality of care with improved efficiency.¹
A diagnosis International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code documentation is the primary requirement, and mapping the ICD-10-CM codes with the correct (HCCs) in the medical chart will determine the appropriate usage of Medicare reimbursements.
A retrospective risk adjustment coding solution is helping Medicare Advantage (MA) organizations as it allows them to uncover HCC codes supported by the medical record which were not reported, and the ones that should not have been submitted because they did not match criteria of MEAT and ICD-10-CM coding and reporting guidelines.
To avoid mismatch, it is always recommended to adopt a retrospective HCC code review approach and eliminate costly errors.
But, what are the most common challenges faced by MA organizations when shifting risk adjustment vendors?
1- Cost: No matter how effective, efficient, sophisticated, or otherwise – cost is always an issue.
2- Chart retrieval: Incomplete chart retrieval! In need of a partner that can retrieve large as well as small volumes of charts cost effectively!
3- Efficiency: A multitude of variables, individuals, processes, technology, changing environments, compliance, risk, etc. create complexity impacting accuracy and are constantly managed.
4- Accuracy: A multitude of variables, people, processes, tech, changing environments, compliance, risk, etc. create complexity impacting accuracy and are a constant management burden.
5- Compliance: In need of an efficient technology to reliably manage CMS compliance as well as internal and external audits.
How Metacare AI Retrospective HCC Code Review APIs can help MA organizations
- Metacare AI natural language processing (NLP) software as a service (SaaS) platform is an artificial intelligence (AI)-based technology that processes the ingested raw patient data – both unstructured and structured format from multiple sources and transforms them into a usable form.
- Tried and tested on 10’s millions of real clinical patient data (charts).
- Successfully applied for CAC and CDI now demonstrably customized for risk adjustment (RA).
- Uses industry-leading knowledge graph-infused clinical NLP technology to bring you better outcomes. Get auto-code suggestions, review charts, validate codes and get actionable clinical insights right at your fingertips.
- Performs automated quality analysis (QA) review using AI/NLP technology on the medical charts & HCC coding supports health plans, medical coders, and providers with Retrospective chart review & audit solutions.
Why choose Metacare AI NLP technology for retrospective code review
a) Drive appropriate compliant and efficient HCC code capture
b) Reducing errors and improving HCC coding quality
c) Deep-dive into the internal claims process, and know underlying problems or high-risk areas based on the adjudication results (paid claims, denied claims, pending claims).
Some additional benefits of using Metacare AI NLP-Powered Retrospective Review Risk Adjustment Solutions
- No workflow risk as you can get started with Metacare AI NLP technology without making any changes to your existing workflow & costly integrations
- No timeline risk as your existing workflow remains intact, you can still do project delivery without our results
- No financial risk as Metacare AI HCC Coding QA Review Solution is free for the first 1,000 charts
- A partnership based on trust and collaboration
- Secure, scalable, and compliant
- We combine coders with technology to ensure accurate risk adjustment codes.
You can look nowhere further as we are here to help you try our HCC code review solution which is free for the first 1,000 charts and based upon its accuracy, efficiency, and usability you can back your decision, of continuing further with it, by the experience you receive.
Book a discovery call to know more
¹Total Health Care