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Exceptional Coders | Innovative Technology

DaVita Subsidiary Settles Risk Adjustment Billing Case for $270 Million

Posted by David Fong on Nov 15, 2018 8:00:00 AM

Modern Healthcare reported recently that DaVita Medical Holdings will pay a $270 million settlement to the federal government over allegations that the company incorrectly inflated certain Medicare Advantage reimbursements above the fixed, risk-adjusted rate owed for care.

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Topics: Risk Adjustment, Medical Coding, Coding Compliance, Medical Coding Audits, HCC Coding

Proposed CMS Risk-Adjustment Changes Could Lower Medicare Advantage Revenue

Posted by David Fong on Mar 9, 2018 12:30:00 PM

Modern Healthcare reported in a recent article that health insurer and provider groups were complaining about the CMS' proposal to use more patient encounter data to determine Medicare Advantage plans' risk scores in 2019, saying the data could reduce payments for plans.

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Topics: Medical Coding, Outsourcing, Risk Adjustment, HCC Coding

DOJ Takes Action on Medicare Advantage Overpayments

Posted by David Fong on Sep 28, 2017 6:00:00 AM

As you are well aware, Congress created Medicare Advantage (MA) as a risk adjustment payment program that pays insurers more for sicker beneficiaries. Payers in MA receive a yearly fee for each enrolled member and monthly risk adjustment payments for each enrolled beneficiary, based partly on the person’s health status. This program can be open to fraud. Medicare Advantage payers received about $160 billion in 2015 for approximately 16 million beneficiaries. HHS estimates that the FY 2015 Medicare Part C gross improper payment estimate is 9.50 percent or $14.12 billion, along with the FY 2015 net improper payment estimate of 4.32 percent or $6.41 billion.


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Topics: Medical Coding, HCC Coding, Medical Coding Audits, Coding Compliance

Better Coding and Record Keeping Can Improve Care and Reimbursements for High-Risk Patients

Posted by David Fong on Aug 29, 2017 7:00:00 AM

An article in Modern Healthcare magazine reported that physicians who serve low-income patients with complex conditions are more vulnerable to financial losses in value-based payment models. The study that found these providers, many of them safety-net providers, didn't have the technological infrastructure to report the necessary data.


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Topics: Medical Coding, HCC Coding, Medical Coding Audits, Coding Compliance

HCC Coding Needs Rise as Medicare Advantage Gains Increased Popularity

Posted by David Fong on Jul 21, 2017 7:00:00 AM

Medicare Advantage (MA) is a complex program that continues to gain popularity, with about one-third of Medicare beneficiaries currently enrolled in a variety of MA programs. MA plans are issued by MAOs, or Medicare Advantage Organizations, that are typically insurance companies.

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Topics: Medical Coding, Revenue Cycle Management, HCC Coding