Monitoring is Key to Guard Against HCC Gaming

by Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE, FHFMA

At the end of last year,  this news may not have caught your attention:

Federal Auditor Renews Concerns of Medicare Advantage Gaming
Axios, December 12, 2019

“A new federal audit presents more evidence that private Medicare Advantage plans are fudging the data about how sick their customers are, as a way to pull in more taxpayer dollars.

Medicare Advantage plans received $6.7 billion in federal funding in 2017 based on diagnoses — like cancer or heart disease — that were not reflected in the actual care patients received, according to the report from the Office of Inspector General.”
Source

Coding and HIM professionals working in an HCC environment can help protect their organization from fines and penalties due to HCC Gaming. Routine monitoring of trends by provider is a great place to start.

Comparing a provider’s activities to those of his/her peers in the same specialty in the practice will help identify a provider with unusual trends. The information may also be shared with the provider to show him/her how he/she is doing compared to his/her peers.

Here are three items to monitor:

  • Total HCCs by Provider vs. by their Specialty
  • Top 5 HCCs by Provider vs. by their Specialty
  • Top 10 Diagnoses by Provider vs. by their Specialty

Any significant variations for a provider from their specialty is a starting place to do a deeper dive to ensure the provider’s coding is accurate, that the documentation supports the conditions claimed, and to avoid any gaming of the system.

 

Gain a deeper understanding of HCCs and other risk adjustment methodologies. HCC: Fundamentals of Hierarchical Condition Categories by Rose T. Dunn, MBA, RHIA, CPA, FACHE, will help you to go beyond just the diagnoses — really understand the methodology behind HCCs!

About the Author

Rose Dunn
Rose Dunn is the Chief Operating Officer at First Class Solutions, Inc., a healthcare information management leader since 1988. Rose is the author of “The Revenue Integrity Manager’s Guidebook” available from the National Association of Healthcare Revenue Integrity and other books on Coding Management and Auditing from HCPro. She engaged herself in ICD-10 more than 10 years before it was implemented. She is assisting Libman Education in the development of an HCC educational program. Rose holds a BS and MBA from Saint Louis University.

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