Every value-based care (VBC) provider understands that accurate risk adjustment is crucial to understand their patients, predict future care costs, and access fair reimbursements from the Centers for Medicare & Medicaid Service (CMS). But is this best achieved through retrospective or prospective coding reviews?
This article explores both options, offering a clear overview to help providers determine the best approach to risk adjustment.
Risk adjustment coding enables medical professionals to predict their future resource utilization so they get reimbursed appropriately for their services. As a healthcare service provider, you must ensure that the healthcare payment claims you submit are error-free.
The consequences of not doing are serious: the CMS’s most recent review found that over $40 million worth of improper payments were caused by improper documentation, while 9.5% of Medicare Advantage payments are found to be inaccurate due to unsupported diagnoses.
The takeaway? Inaccurate claims lead to a lot of missed funding and administrative chaos. Errors in your hierarchical condition category (HCC) coding can also lead to external audits or fraud investigations, which are stressful and will delay your reimbursements.
This is why you must do everything possible to prevent coding errors, and the best way to avoid these errors is to review HCC codes. Providers must thoroughly review or audit your claims to avoid delays in submission and reimbursements, which can negatively impact your facility’s finances and ability to operate.
Now let’s explore the two most important HCC coding review processes: prospective and retrospective coding reviews.
A prospective coding review is the process of analyzing your HCC codes before you submit your healthcare payment claims. The main objective of a prospective coding review is to catch coding or billing errors before the submission is made.
This coding review focuses mainly on specific and targeted cases chosen in accordance with the guidelines issued by the Office of the Inspector General. These cases can also be selected from high-risk areas you identified from previous external audits.
Your risk adjustment coders will evaluate the patient’s HCC codes, prescriptions, medical records, test results, and doctor notes to establish the correct risk factors for your billing and payment claims. During this process, ensure that your coders don’t miss any essential codes.
Missed HCC codes can negatively impact your finances because you won’t be reimbursed appropriately. You must also ensure that HCC codes have been properly documented and recorded in the patient record.
Retrospective coding is the process of reviewing HCC coding information after you’ve delivered the necessary medical services and submitted your healthcare payment claims. This process helps to uncover any HCC codes that were missed during the submission as well as any HCC codes that shouldn’t have been included.
Failure to comply with the HCC code documentation guidelines can have serious consequences, including fraud investigations. Because the retrospective process happens after the fact, if there are any documentation issues uncovered, they may end up being a longstanding and ongoing problem you will need to spend precious time dealing with.
Retrospective coding also needs a secondary procedure to highlight the wrong codes and resend the claim with the correct codes to the payers. This coding process is common with Medicare Advantage plans.
Medicare Advantage plans use the Alternative Submission Method, and it’s not difficult to submit retrospective HCC code adjustments. Unfortunately, this process can be quite cumbersome with other payment plans.
For the Medicare Advantage plan, the prospective coding process can seem cumbersome and superfluous at first. However, prospective reviews are less disruptive than retrospective reviews and can yield great operational and monetary benefits because it makes sure the codes are right before submission.
This minimizes time wasted because you don’t have to do corrections and do-overs after submission. If you do proper prospective HCC coding, there won’t be any need for retrospective coding. It also helps you avoid disruptive external audits and fraud investigations because you get your payment claims right the first time.
With the help of advanced HCC coding solutions like Inferscience, you can carry out your prospective and retrospective coding quickly and accurately to avoid delays in reimbursements, as well as to improve overall patient care.
Prospective coding can be highly time-consuming, forcing providers to shift focus away from their patients. This not only impacts the patient’s experience, but it also often leads to human errors that result in the need for retrospective coding – and ultimately wastes a lot of time.
Artificial Intelligence (AI) has the potential to solve this problem. With automated coding solutions, providers will be able to quickly assess and select HCC codes during their normal workflow. This will enable fast, accurate prospective coding that doesn’t disrupt care or burden providers.
The perfect example is HCC Assistant: our tool uses natural-language processing (NLP) to ingest structure and unstructured medical data, before analyzing it and producing accurate HCC coding recommendations at the point of care. This allows you to carry out both prospective and retrospective coding quickly and accurately to avoid delays in reimbursements, as well as to improve overall patient care.
Want to see it in action? Book a Demo
References:
https://www.mdaudit.com/blog/prospective-vs-retrospective-audits-our-view-you-need-both/
https://www.rcxrules.com/blog/prospective-concurrent-retrospective-review
