Peak’s comprehensive HCC Risk Adjustment services are designed to meet your financial goals while ensuring CMS compliance.
We provide an end-to-end solution from Suspect Identification through RAPS submission, including continuing education and support for your physicians and coders. We offer comprehensive retrospective, prospective, and auditing reviews to ensure your medical records contain accurate & complete ICD-9-CM codes. Accurate HCC codes are vital to your success. Accurate codes provide a higher return on investment (ROI) and improve patient care through accurate record keeping.
Retrospective Medical Record Review
A Retrospective Record Review is one of the best ways to reduce current audit and regulatory exposure and establish a foundation of accurate and compliant coding and documentation for the future. Our Retrospective Medical Record Reviews:
- Confirm or deny all claims data submitted to CMS for the specific year of review while locating inaccurate and missing codes to obtain the most precise risk score for your members.
- Correct incomplete medical records & improve physician documentation.
- Identify, monitor & quantify risk for potential revenue loss in a RADV audit.
- Are performed by Peak’s staff of Medicare Advantage experts which are all credentialed, multi-specialty coders and auditors.
- Provide monthly revenue estimates & reports.
- Schedule, scan & store medical record images for future audits and physician education.
Concurrent Medical Record Review
The Prospective Medical Record Review Audit is a powerful device for identifying and preventing substandard documentation and coding, and for building an optimal and appropriate HCC Plan profile. Our clients can utilize the data to:
- Optimize Risk Scores
- Identify ICD-9-CM code errors and enhance current and future coding accuracy.
- Recognize provider documentation weaknesses and identify opportunities for clinical documentation improvement (CDI).
- Proactively capture missed HCC/RxHCC classification opportunities in the current calendar year.
Long Term Benefits of a Concurrent Medical Record Review:
- More appropriate member care.
- Improved Physician Documentation and decreased CMS errors.
- Better preparedness for impending RADV Audits.
Our clients can take charge of the HCC profiling and reporting process which enable them to:
- Lower administrative costs by ensuring the RAPS data is correct during initial submissions.
- Strengthen provider documentation and identify providers for ongoing CDI purposes.
- Monitor and pre-audit providers with continuing documentation errors.
- Analyze and identify ICD-9-CM coding patterns and opportunities for coding improvement.
- Identify missed HCCs and ascertain HCC suspects for potential HCC/RxHCC classification.
- Mitigate and manage audit liability as a result of the CMS-led RADV audits.
Peak analyzes the pre-selected claims data in order to:
Ensure correct federal reimbursement and risk adjustment factor rate setting.
Adhere to federal coding and documentation compliance standards.
Afford opportunities to monitor and strengthen provider documentation.
Lower administrative costs (less corrective steps) as a result of cleaner RAPS file submissions.
Health Risk Assessments
The Prospective Health Risk Assessment is the most efficient and precise method for obtaining timely and accurate information that affects Plans’ Risk Adjustment Factor Score. Peak utilizes a prospective HRA program in order to document and quickly process all member-derived data to our clients. The Prospective HRA is an invaluable tool for optimizing the risk adjustment score of your Medicare Advantage population. During Peak’s comprehensive on-site Health Risk Assessment, the following areas of clinical diagnostic information are obtained and documented:
- Pertinent member demographic information
- Past medical history, including personal and familial history/treatment of specific diseases
- Relevant social history including lifestyle habits impacting short- and long-term health
- ADLs and relevant restrictions affecting the patient’s mobility and functioning
- Current medication inventory
- Comprehensive review of systems
- Provider list (current and previous providers)
- Member vital signs and physical evaluation
- Assessment of cognition and depression indicators
- Preliminary laboratory specimen collection
- Comprehensive diagnosis registry
- Recommendations for care plan as well as referrals for provider follow up
Immediate and continuing benefits to Peak’s Health Risk Assessment services:
- Timely and accurate identification of HCCs/RxHCCs via ICD-9-CM Code Assignment & Report Risk Data
- Development of a Framework for Appropriate Care Plan Management
- Implementation of Fiscal Controls
