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Hi everyone. This is Michael Miscoe with Miscoe Health Law. With this week’s installment of ChiroSecure’s Growth Without Risk. I don’t know what we call this podcast series. In any event, today we’re gonna talk about record requests associated with what are called HCC risk Adjustment Validation Audits.
HCC stands for hierarchal easy for me to say. Condition classifications, and essentially what it is, every code in ICD 10 is mapped to a category. Now not all of those categories necessarily influence what’s called the HCC Risk score, but what this process does for Medicare Part C plans also used to be known as Medicare plus choice.
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Now it’s called Medicare Advantage, but it’s part C of the Social Security Act. Provides basically coverage for Medicare. What would otherwise be Part B or outpatient services through. Part C and essentially those services are paid for by commercial insurance companies that qualify as what are called Medicare Advantage Organizations, MAOS.
And what they do is they offer Medicare outpatient coverage to the public. There’s a premium that they pay, but the way that they get paid is they get a fixed or capitated payment for each member that they sign up based upon how sick. The patient is. So the sicker the patient, the more money they get.
MAOS are very interested in appropriate documentation of a patient’s conditions. Now, th this, these risk adjustment audits also apply to a CA exchange plans that are subsidized by the federal government because they’re subsidized in the same manner. So if you have, a commercial insurance carrier selling exchange insurance plans that are subsidized by the government because of the patient’s income.
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They qualify for a subsidy then. That the value of that subsidy is also based upon how sick the patient is. So what happens is that when they are validating the risk score that they are reporting to CMS. So understand that, think of it like the MAO is billing CMS for reimbursement. Okay?
And the way that they bill is they report what’s called an HCC risk score. For a particular patient to CMS and in CMS based upon that risk score, then determines the amount of a capitated payment that they’re gonna make to that insurance company, which that insurance company then has to use to pay for all of that person’s healthcare needs for the coming year.
You have a reporting year and you have a payment year. So let’s say for example, this year’s HCC risk score that they develop determines how much they get paid to ensure that person next year. So what happens is that they will sample the patients that they are reporting risk scores to CMS for and.
When they determine the risk score, it’s based upon billing data, diagnosis codes that doctors submit with their claims. And then what they do is they go back and they will pull documentation to validate that those diagnoses are justified. And more importantly, they’re also looking for evidence of conditions that did not get reported on claims that were submitted for reimbursement.
And when I say claims submitted for reimbursement, I’m talking from the doctor to the payer now. Under the premise that most of you tuning in are chiropractors, the only thing you’re gonna be submitting to a Part C plan usually is manual manipulation of the spine CMT codes in which case your diagnosis is are gonna be subluxation and some associated neuro musculoskeletal condition, many of which are not even mapped to HCCs.
However, that does not mean that there may not be evidence in your records of some. Other more serious comorbid condition that you’re not treating, but nonetheless, that you have diagnosed either through x-ray, maybe because of records you’ve obtained from a patient’s other treating provider, whatever.
So you’ll get one of these requests and it seems that lately there’s been a bunch of these coming out and docs being sensitive to requests for records from an insurance company lose their minds and panic before they read. Now the request for records will always come from I won’t say always, but 99% of the time the request is gonna come from a third party contractor operating on behalf of say, Anthem Blue Cross or XYZ, blue Cross, or Cigna or Aetna, or some other commercial payer, and it’ll have a cover letter.
And they will tell you that they have been, they’re a third party auditor, whatever, working on behalf of this other insurance company. And you’ll see if you read carefully an indication that the reason that they’re requesting these records is it’ll either come out and say risk validation.
It’ll say something about Medicare Advantage HCC hierarchy of condition categories. But when you see that. Okay. You don’t need to worry because this isn’t an audit about the compensability of your services. They are looking for records so that they can validate that the submissions that they sent to CMS for their capitated reimbursement, that those submissions were accurate and they and the HCC score was justified.
At the end of the day, when you get one of these, and I should mention like some of the contractors like ox data van they’ll have a fax cover thing and they’ll identify, usually it’s one patient, but it could be more than one. But they will identify the patients and the dates that they want records for those requests.
You can submit those records without concern that. Someone’s gonna drop a big hammer on you and ask for a boatload of money back. I have never seen one of those turn into a post-payment audit situation. That doesn’t mean that it necessarily couldn’t, but it, I’ve just never seen it happen.
Because the purpose that they’re looking for the records has nothing to do with you. It’s not the contractor’s special investigations department. Again, when you read that letter, two things will stick out. One, it’s a contractor working on behalf of the payer that you submitted claims to. Two, you’ll see the words risk validation as part of the Affordable Care Act.
We’re required to, validate, words to that effect. And if you’re really unsure reach out and have someone that. That is familiar with these things, review it and validate for you that it is a risk adjustment audit request and not a a, post-payment recovery audit.
One other thing that, that is a telltale sign, when you look at the patients included in the audit, they will exclusively be Medicare Advantage patients, people with Medicare Part C and or exchange plans. Now the exchange plans, you’re not gonna know. The group number would in theory tell you if you had a way to dissect the group number and know that it was a subsidized exchange plan.
But the Medicare part C stuff, you should know that those are going to a commercial payer. And they’re med and. They’re covered under Medicare Part C, so hopefully that eliminates a degree of stress in your life. If you should get one of these requests make sure that you sensitize your staff.
You want look at all. Record requests with some degree of scrutiny, but these particular kind of ones are ones that you don’t need to worry about. So I hope that is helpful. And we look forward to seeing you next month on our next edition of the ChiroSecure Growth Without Risk Podcast.
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