How to optimize your coding with Medicare Advantage Payments

The Medicare Advantage plan, sometimes called Medicare Part C or an MA Plan are offered by private companies that have been approved by Medicare. Today roughly 25% of all enrollees in Medicare are covered by an Advantage plan.

Billing under an MA Plan can be a lucrative and profitable part of your practice's income stream - but do you know how to optimize your billings to make sure you're receiving the highest level of reimbursement?

Coding correctly for an MA patient can mean an increase in your payments by 200% to 300%, but it can be time consuming and challenging to learn the correct coding.

There are many factors that affect the rate that CMS pays for a an MA plan, one of the most important is the Hierarchical Condition Category or HCC.

The HCC is a payment model that CMS uses to adjust plan payments made at the patient level based on risk. What this means is that two different patients in the same geographic area can have different payment rates based on multiple factors that relate to the amount of risk or the amount of work is required to maintain the overall health of the patient.

Beneficiaries are assigned a risk score which measures their relative risk. The risk score is then used to adjust payments for each beneficiary. By adjusting plan payments based on risk CMS is able accurate payments for enrollees in a plan with differences in the expected cost of their care.

While there are several factors used in calculating the raw risk score, the two factors are the enrollee's health status and their demographic characteristics. The combination of these two factors determine the Raw Risk Score.

Raw Risk Score = Patient Demographics + Health Status

Since you can't influence the demographics the only way you can affect a patient's raw risk score and therefore the payment is to make sure that you are accurately documenting the patient's Health Status by billing the proper ICD codes.

 To see an example from an Anthem Health Plan of how proper documentation affects the HCC and ultimately the payment please click here*

*this example was published in 2012 and uses ICD9 codes, much has changed since then but the overall theory is the same.

NextGen Office EHR/PM is Designed to Optimize Medicare Advantage Payment

The NextGen Office EHR/PM is the only EHR with a unique risk assessment tool that helps make sure you are coding correctly to optimize your Medicare Advantage billing.

Learn more about how HCC impacts your Medicare Advantage Payments. Get a free copy of our white paper "The Medicare Advantage HCC Program: How to Optimize your Coding"