BOSTON, Feb. 11, 2014 /PRNewswire/ -- MedAptus® today announced that it has released a Risk Severity Toolkit to help provider groups measure and manage the disease burden of patients covered under risk-based contracts. The initial version focuses on the Medicare Advantage (MA) patient population where premiums paid to MA health plans are based on enrollees' severity history using the Centers for Medicare and Medicaid Services (CMS) Hierarchical Condition Categories (HCC) model. Providers are increasingly at risk under contracts with MA plans, both financially and administratively, to properly document and manage patients' clinical risk.
In 2004, CMS upgraded its method to adjust capitated payments to MA plans using the HCC model, based on health expenditure risk of enrollees. Prospective risk estimates are based on patient demographics and conditions documented from encounters occurring in previous and current years. The process of HCC coding can pose a challenge to physician groups because CMS requires new problem documentation each year to create a current profile of member risk. If severity is not documented in an accurate and timely manner, payment is reduced to the health plan, and increasingly to providers as well under their contracts with, or as sponsors of, these plans.
MedAptus has a demonstrated ability to leverage data within its Pro Charge Capture software to drive complementary, clinical data collection, such as with the company's PQRS and P4P functionality. Similarly, the MedAptus Risk Severity Toolkit now eases the process of HCC coding. The first step is an alert when a MA patient has an office visit and requires a severity evaluation and diagnosis documentation. From here the Toolkit profiles documented patient demographics and clinical conditions relevant to the HCC model, both prior and current year, for provider review during the encounter. The detailed Patient Severity profile also applies the HCC model to quantify the patient's severity scores based on those histories. Providers can quickly re-assess the patient's past and current clinical status to properly document new or continued manifestations requiring management. The Toolkit also includes analytical reports to compare patient severity scores over time across all at-risk health plans.
"Across our customers, it's evident that risk is shifting to providers based on clinically-based performance measures," said Dennis Bush, who manages MedAptus' Reporting and Analytics products. "In our development of the Risk Severity Toolkit, the immediate challenge we recognized is how to assure that clinicians properly assess and document conditions to correctly measure severity scores. Based on customer feedback, we have a practical solution, fitting naturally into the clinical workflow of providers."
The timing of this product release will help provider organizations on several fronts. Once ICD-10 goes into effect later this year, the number of diagnosis codes mapping to HCCs will increase, making this process even more complex for groups. Secondly, enrollment in private MA plans has been on an upward trajectory, with over 14 million covered lives in 2013, compared to 12 million only two years earlier. And CMS has aggressively audited, challenged, and recovered billions in excess premium payments to MA plans, who are in turn pressing providers for proper documentation.
"Traditionally, risk has been assumed primarily by purchasers and payers, but with the movement to value-based medicine and emerging ACO payment models, providers will absorb more risk, placing greater emphasis on the need for appropriate encounter documentation and both financial and quality management of that patient risk. Our Risk Severity Toolkit is a strong platform to accomplish these objectives given its leverage of demographic, visit and charge information within the MedAptus database," added Bush.
About MedAptus Corporation
MedAptus is the Gold Standard in the healthcare revenue cycle for achieving effective charge management, compliance and workflow efficiency. With offerings that include powerful and easy-to-use charge capture and management technologies, it is no wonder that many of the nation's most prestigious healthcare organizations rely on MedAptus for financial optimization. Our full-scale Professional, Technical, and Infusion applications increase revenue, enhance EMR investments, re-engineer manual processes and yield substantially improved productivity. For more information, visit www.medaptus.com, or call 617.896.4000.
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MedAptus Contact: Jennifer Crowley