Risk Adjustment Takes Center Stage Under the Value Care Model, Raul Kivatinetz (1 ML)


Raul Kivatinetz


There are two sayings, “If it’s not documented, it didn’t happen” and “Follow the money.” This is certainly true when capturing the patient’s story; a provider sees a patient, creates an encounter note, submits the claim, and (hopefully) receives reimbursement for services rendered. Fee-for-service (FFS) care is migrating to Value-Based (VB) care; a payment model rewarding healthcare providers, including hospitals and physicians, based on patient health outcomes. With 80% of patient encounters happening within physician offices, accurate and complete documentation is key to avoiding delayed payments or denials. CMS introduced Risk Adjustment (RA) when Medicare Advantage (managed care model) was created. RA was then expanded to ACA health plans and Medicaid. With the transition to Value Care payment models CMS has strict documentation/coding requirements, resulting in incentives and penalties. If the claimed diagnostic codes lack supporting documentation, it’s considered FRAUD! Not coding to the highest specificity based on the documentation is under-coding and leaves money on the table for first submission of claims (average of $1200 per member per year), impacting payers, managed care organizations (MCOs) and providers! Learn how documentation directly impacts revenue, CMS compliance and audit risk. See how expert systems (AI, natural language processing, and machine learning) are used to support value-based healthcare.  

Learning Objectives
1. Historical facts and basic Risk Adjustment (RA) = Reimbursement ($$)
2. CMS Requirements – For health plans, ACOs and MCOs
3. How to meet M.E.A.T. – Document, document, document!
4. How expert systems (AI, NLP, ML) are coding healthcare documentation
5. Under- or over-coding – Find the hidden value that impacts measured outcomes