And the Survey Says… Claims based submissions are scary

September 7, 2011
|In Compliance, Risk Adjustment
|By GHG Advisors

During our September 1st webinar, Risk Adjustment: Vulnerabilities in Claim Based HCC Codes, we asked our health plan attendees a few questions about claims-based HCC codes.  Here are the answers.

What percentage of your HCC submissions comes from claims?

  • 25% of the health plans answered 45-60%
  • 21% of the health plans answered 61-80%
  • 44% of the health plans answered 81-100%

Studies indicate that between 60-80% of all HCCs comes from claims submissions. However, we also know that between 17-44% of all claims-based HCCs fail a CMS RADV audit.  We must verify the validity and accuracy of health plans’ claims-based submissions.  How can we do that?

CenseoHealth’s CareCurrent provides continuous data analysis, reporting and production management designed to mitigate HCC risk.  This analysis not only supports a health plan in determining the confidence levels of the ICD-9s that trigger HCCs; the service also indicates how to remediate high-risk codes with chart review or a member evaluation.

Next we asked —

Do you filter your claims based HCCs?

  • 50% answered yes and 50% answered no

That is a little scary and the health plan’s next RADV audit may be even scarier.  Scrubbing your claims based HCCs is a critical part of the mock RADV audit process and the foundation of RADV “proofing” your risk adjustment program.

Finally we asked —

How frequently would you or should you scrub your claims based HCCs?

  • 55% of the health plans answered monthly
  • 45% of the health plans answered quarterly

Both are good answers.  We recommend running a claims based filter in late September so you can resolve any low confidence codes with chart review or member evaluations prior to the end of the calendar year.  We also suggest running a claims based code analysis at the end of December to ensure the health plan deletes any unsubstantiated codes before the January 2012 sweeps.