Hierarchical Condition Categories (HCC)model is used by the Center for Medicare and Medicaid Services (CMS) in order to track risk adjustment of the Medicare Advantage Program. There are many HCC categories that consist of specific diagnosis predetermined by CMS each year. The conditions must be coded properly in order to qualify in the appropriate category. The burden of properly reporting and documenting the condition falls directly on the provider.
Medicare Risk Adjustment (MRA) coding is the process CMS uses to reimburse Medicare Advantage plans based on the ICD conditions reported for each member. These conditions are revised each calendar year. Providers that contract with Medicare and Medicaid are required to adhere to this reporting methodology.
Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by health plans to measure the performance of each provider on important aspects of care and service. The categories used to measure the performance of each provider are predetermined every year by the National Committee for Quality Assurance (NCQA).
HEDIS measures are specifically defined, thus allowing the health plans to compare providers’ performances in a standardized manner. Providers that fail to address and/or properly report and document these measures risk having their contracts cancelled by the respective health plans.
Southeast Physician Associates has a staff that includes Registered Nurses and Certified Coders. They perform chart and claims audits to ensure that all conditions are documented and coded to the highest level of specificity. Our staff follows the guidelines set forth by the American Medical Association (AMA), American Academy of Professional Coders (AAPC), and the Centers for Medicare and Medicaid Services (CMS). Southeast Physician Associates offers a medical billing service that reports encounters for many of its contracted physicians.
Complying with HEDIS is directly linked to properly coding each measure performed by the physician. Using a certified coder with expertise in HEDIS is an essential part of the physician’s success.
Recently primary care physicians have experienced annual reductions in payments while their cost of doing business has gone up an average of 3 percent annually. Maintaining high quality of care in this environment is challenging.
Services we offer to our physician partners include: MRA and HEDIS auditing and coding, referrals, daily census, medical billing and coding, contracting, continuing education, training, payroll and staffing.
In addition to physician and physician groups, Southeast Physician Associates provides MRA and HEDIS auditing services to health plans, staff-model medical centers and other MSOs and IPAs.