Care management
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3 Ways to Improve Reimbursement Accuracy
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Efficient Ways to Improve Reimbursement Accuracy
Being accurate and efficient is key to driving success and in maintaining a smooth flow of operations, failure to do so can negatively impact an organization. By keeping a close check on reimbursement accuracy and putting into place the necessary methods and steps required to sustain a steady and accurate reimbursement will prove beneficial for all levels of the organization.
The RADV audit was formulated with the purpose of ensuring consistent reimbursement payment accuracy for Medicare Advantage Organizations. According to the most recent 2023 Final Rule, CMS has released their plan for the overpayment extrapolation beginning with payment year 2018. The impact of medical reimbursement loss may affect the whole organization and trickle down to the member level.
As stewards of healthcare, plans have the important responsibility to enhance their risk mitigation activities and reduce inefficiencies to ensure reimbursement accuracy.
3 Ways to Improve Reimbursement Accuracy
- Shift in Documentation Mindset and Coding
Provider education is a crucial tool to shift the documentation mindset away from a fee-for-service approach and move toward a more value-based care model, where the diagnosis is supported by clinical evidence. The value-based care model is preferred due to its focus on quality of care, provider performance, and patient experience. This then enables the coders to effectively identify and capture diagnosis codes pertinent to the visit and not confound diagnoses from a past medical history or chronic condition list, reducing coding inaccuracies and ensuring proper reimbursements.
- Emphasize Prospective and Concurrent Review
Retrospective review will always be viewed as relevant, but ensuring the documentation is captured as you go, concurrently and prospectively, has proven to be a far more effective approach. This makes sure that the diagnosis coding is accurate and supported, thereby lowering any risks of reimbursement. It's essential to capture as many current-year gaps as possible for the submission year to ensure reimbursement accuracy.
- Conduction of Internal Quality Assurance Audits
Quality should be an area that can never be compromised, and maintaining a consistent level of high quality is an important objective of any organization. Whether the organization makes use of providers coding, uses their own coders internally, or outsources coding from elsewhere - consistent standards of quality is a critical attribute and maintaining the same level of standard, without fail or any inconsistencies, should be a key focus area. Regular quality assurance audits, provider education completed post-audit, and post-education follow-up are potent tools to ensure the education is effective and improves the levels of quality.
