Advantmed, LLC, an integrated risk-adjustment optimization and quality improvement company, introduces Physician Record Review (PRR), a two-stage retrospective chart review process, first by a certified coder and second with a board-certified physician. This empowers Medicare Advantage plans with clinical insight into risk adjusting conditions to enhance traditional analytical platforms.
"The ability of physicians to review progress notes for primary care, specialists' hospital charts, radiology and laboratory results not routinely used in standard analytics provides for more demonstrable actionable information," says Nilay Shah, president of provider solutions for Advantmed. "Additionally, PRR identifies care opportunities in accordance with evidence-based medicine. The Advantmed physician staff are board-certified in their area of specialty with extensive risk-adjustment training to uncover the potential for risk-adjusting conditions not identified by current programs."
Shah says that PRRs represent one of the best opportunities to focus on Hierarchical Condition Categories (HCCs), explaining, "Our team of physician reviewers identifies HCCs within each patient chart, annotates risk adjustable conditions by page number, and integrates these outputs into a broader array of activities."
CMS uses HCCs to reimburse Medicare Advantage plans based upon the health of their members. It pays for the predicted cost expenditures of patients by adjusting those payments based on demographic information, Medicaid status, and the severity of illness or patient health status as recorded in medical record documentation.
"Advantmed PRRs also confirm the previous two years of submitted HCCs for clinical confirmation not currently submitted in the calendar year," Shah says. "The goal is to provide a complete picture for the risk adjustment factor, increasing the accuracy of the patient's risk score and, ideally, creating clean claims and faster reimbursements."
— Advantmed, LLC