Medicare Risk Adjustment (MRA) serves as a cornerstone for successful managed care and accountable care practices, organizations,, and associations. While a well-executed program can propel an organization toward immense success, it can also expose it to significant vulnerabilities, deficiencies, and risks.
The challenge at hand is multifaceted, and any endeavor to establish an MRA-compliant organization must be multi-level, multi-departmental, consistent, continuous, systematic, and methodical.
These are some of my reflections on how to develop an integrated approach toward MRA compliance:
- Compliance Over Codes: First and foremost, it’s crucial to understand that MRA follows compliance, not the other way around. The focus should always be on providing the best possible care for patients. Document all relevant conditions, regardless of whether they trigger specific Hierarchical Condition Category (HCC) codes. Mistakes should be corrected promptly.
- Team Effort: MRA compliance is not the sole responsibility of one department, specialty, or silo. It must be a collaborative effort across the organization. Leadership needs to consistently support this initiative, addressing resistance and challenges. Continuous communication and feedback are vital.
- Relationship Management: Relationship management is a sine qua non. I have personally visited about 300 providers in the last 4 months and talked to them, taken their feedback, and reviewed their numbers, strengths, and opportunities. In this process, I have gained valuable insights into their offices, their challenges, and about our processes. This cannot be a top-down approach but providers and their staff have to be closely involved throughout. Building strong relationships with healthcare providers is indispensable. Engage with them, understand their challenges, and involve them in the compliance process.
- Results Over Targets: Rather than fixating on a specific numeric target, focus on achieving compliant MRA. Identify billing patterns and opportunities, but don’t set arbitrary scores as the ultimate goal.
- Incentivization: Implement correct and compliant incentive structures. Providers should be motivated to invest extra time in reviewing patient history and records to ensure accurate documentation. Bonuses for quality, compliance, patient satisfaction, net promoter scores, patient safety, wait times, etc. can and should be considered and implemented.
- Knowledge-Based Approach: Keep the MRA compliance program updated and relevant through ongoing research, learning, reference confirmation, and communication with subject matter experts. A learning organization is best suited to manage MRA initiatives.
- Education: Extensive and engaging education for providers, staff, leadership, vendors, and administration is paramount. Utilize various learning methods, including multimedia, face-to-face training, social media, and mobile apps. The goal is to change habits among professionals and adults but once accomplished, the rest becomes easier.
- Operational Synergy: Foster collaboration among various departments, including clinical, IT, finance, compliance, and risk management. Integrated data sharing and authentic data are key.
- Technology Integration: Leverage technology to streamline workflows, from doctor documentation to ICD coding and billing. Real-time data is essential for effective operations.
- Ascending the Value Chain: This is vital for any IPA or practice as they are the producers of data. They need to consume it in a manner that they can confirm that the data is indeed being transmitted to CMS that they are being compensated for all the diseases documented and that the HMOs are on their toes.
- Correct and Compliant Documentation: This is the most important aspect of MRA. If the physician does not document conditions properly, if the note is not adherent to CMS recommendations, if there is cloning, or if the conditions are not adequately addressed and just strung in a list of diagnoses, then nothing much can be done thereafter. But, if all the patients are brought in, diagnoses validated, gaps closed, chronic conditions brought forward, and suspect conditions addressed, then the rest is a matter of improved management of data and people. The CDIs are an integral factor in ensuring that this is accomplished. I usually spend an hour with the whole team of our CDIs, who work remotely, twice a week to ensure that they are compliant, precise, focused, valid, and motivated.
- Revenue Cycle Management: Though part of operations, merits a separate consideration since ensuring more than 4 HCC codes can be transmitted, that the coders and billers are trained and certified and audited themselves, that rejections are worked along receipt of claims by CMS and their acceptance can make the crucial difference between mediocrity and excellence.
MRA compliance isn’t for the faint of heart, but when addressed systematically, it can be a source of significant strength for any organization embracing managed care or accountable care.
