By Nilay Shah, President of Provider Solutions
Today, Medicare Advantage (MA) plans must gain clinical insight into risk-adjusting conditions to enhance their traditional analytical platforms. The best way to do this is with a Physician Record Review (PRR), a two-stage retrospective medical record review process from a 1) certified coder and 2) board-certified physician.
The point of such a thorough review is to give physicians the ability to review progress notes for primary care, specialists’ hospital charts, radiology and laboratory results that are not routinely used in standard analytics and gain demonstrable actionable information.
What’s more, PRR identifies care opportunities in accordance with clinical guidelines. Advantmed’s physician staff members are board-certified in their areas of specialty and have the extensive risk-adjustment training to uncover the potential for risk-adjusting conditions left undetected by current programs.
Gaining a Complete Picture
PRRs represent one of the best opportunities to focus on Hierarchical Condition Categories (HCCs). Specifically, our team of physician reviewers identifies HCCs within each patient record, annotates risk adjustable conditions by page number, and integrates these outputs into a broader array of activities.
Advantmed’s PRRs also confirm the previous two years of submitted HCCs for clinical confirmation not currently submitted in the calendar year. 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.
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