APEX CODEMINE
Clinical Chart Reviews and Medical Claims Services
Services
“In the midst of HCC Model changes, let us be your guide to bridge the gap between coding and clinical documentation to achieve optimum HCC results and maximize highest potential revenue”…
Healthcare practitioners are the deciding factor if the condition/diagnosis is implemented and properly documented for a specific enrollee. Some of the challenges we have seen in MA Plans have decreased in patient RAF scores and revenues due: Gaps in documentation & coding, the lack of clinical documentation to support a specific condition, and/or missing technical components required for chart submission.
Risk Adjustment Retrospective Chart Review
While Medicare Advantage Plans rely on HCC system for reimbursement since 2007, it is our nature to effectively adopt a prospective approach during retrospective chart reviews to ensure accuracy and sustain our client’s revenue . To achieve optimum HCC results and maximize potential revenue we offer the following services:
- Our highly trained certified HCC experts provide in-depth focused medical chart reviews
- Drill down clinical data while combining years of coding techniques & logistics
- Identify cases with greatest potential for revenue improvements
- Capture un-coded diagnosis properly supported by clinical documentation
- Capture true conditions that align with the applicable risk model for proper reimbursement
- Risk accuracy and avoid triggers for extrapolated penalties
- Validate and remove unsubstantiated conditions/HCC when after review a risk is found unverified
- Combine detailed analysis utilized for physician education for HCC clinical documentation
- Conduct data validation review process in conjunction to HCC chart reviews
MOCK RADV Audit
CMS conducts Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) activities to ensure payment accuracy of Medicare Part C and Part D Program and protects the Medicare Trust Fund. RADV is the process of identifying and verifying that the diagnosis code submitted for payment by the MA Plan is supported by medical record documentation for each beneficiary.
- Collect and sort all patient records for the measurement year and HCCs to be validated
- Identify physician specialties and target providers to support HCC in conjunction to claims data
- Review primary and secondary records providing levels 1-5
- The best medical records to be used for CMS submission
HCC Coding Materials for Physicians & Coding Staff
Gaps in Documentation and proper coding assignments affects quality measures, outcomes, and proper reimbursements to Medicare Advantage Plans and other managed care programs
- Key to quality assurance and maximize your revenue is to arm your coding staff with simple and yet effective HCC Training Tools & Materials to ensure coding accuracy and positively impact your Risk Adjustment Program
Claims & Fraud Prevention Medical Review and Investigation
As Medicare continues reviewing high dollar claims and developing strategies to identify potential risks, our team of claims processing experts will ensure high dollar hospital and specialty claims are appropriately paid to avoid the potential risks of overpayment. Our process to ensure accuracy includes:
- Verifying Provider Contracts or existing LOAs are in place & properly adjudicated
- Verify Distribution of Financial Responsibility (DOFRs)
- Verify member eligibility & services rendered authorized
- Sufficient documentation of services are supported and appropriately billed
- Determine whether to return, deny or pay claims following organizational policies and procedures
.jpg)