VRCM’s Risk Adjustment solutions offer Health Plans with integrated end-to-end services to significantly improve their performance by identifying uncoded, undercoded, and miscoded opportunities and documentation gaps. We support Health Plans by prospectively identifying potential high ROI members and strategizing their risk adjustment programs.
With the implementation of ICD-10 codes in the industry and mapping of patient diagnosis, capturing accurate information regarding the patient has become extensive and complex. With AAPC or AHIMA-certified coders, we assure accuracy in capturing missing risk-adjusted diagnoses, minimizing errors and ensuring certainty in members being appropriately risk-adjusted and qualified for the risk-adjusted premium. From selecting random charts for audits to ensuring accurate, compliant coding practices, we make sure that all appropriate diagnoses are reported and supported within the medical record, handling the most complicated coding assignments with utmost specificity, and thus facilitating a smoother CMS/HHS submission.
VRCM is one of the few partners with fully trained and experienced staff to support all aspects of Affordable Care Act Risk Adjustment Data Validation (ACA-RADV) requirements. Our demonstrated experience with Medicare Advantage RADV and experienced certified coders helps us conduct detailed inspection cross-checks with client’s past RAPS submission, analyses if it yielded accurate results and offer expert solutions for sustained improvement. With a fully trained and expert RADV quality team to support Health Plan’s RADV requirements, VRCM empowers Health Plans to target the most acceptable medical records for sampling.
Our team of Nurse Practitioners and Coders abstract and accurately report on all HEDIS measures (as per NCQA technical specifications) related to Health Plans’ P4P and Star Program initiatives.
- Measures for Medical Record Data collection
- Adult BMI Assessment, Medication reconciliation post discharge, Care of Older Adults, Comprehensive Diabetic Care, Colorectal Cancer Screening, Cervical Cancer Screening, etc.
- Medical Record abstraction on collected data
- Over Read & Validation
- Track record of executing HEDIS abstraction for 20 measures in the past
- Over 95%+ accuracy
- Over 100 certified Nurse Practitioners and clinical coders
- Robust training program developed by HEDIS technical experts
- Stringent IRR policies and procedures
VRCM provides medical record review services with significant cost savings to MSSP and Pioneer ACOs. We offer quality measure reporting using the CMS GPRO program.
- Reporting by measure , member and provider
- Medical record review based upon GPRO narrative measures specification for clinical Modules – Care Coordination/Patient Safety, Preventative Care, Diabetes, Hypertension, IVD, Heart Failure, CAD
- First mover advantage for the Client
- Robust training program with detailed process flow for ACO measures
- Stringent reliability audits supervised by RN’s
- 95%+ accuracy with flawless execution and outstanding customer support
Clients can leverage VRCM’s Certified Nurse Practitioners and coding resources in undertaking chart audits for Hospitals , DRG & DRG short stay audits & APC validation. Our audit program ensures our clients are controlling costs most often associated with incorrect billing and overpaid facility claims, while reducing overall facility adjudication and reimbursement expenditures.
- Hospital Bill / Chart Audits: Our robust facility claims review process ensures that any overpayments are identified and validated with the facility during the exit process
- DRG & DRG Short Stay review: Our experts ensure a comprehensive review and recoding of medical records based upon the procedures and diagnoses billed by the provider. We ensure appropriate DRG is reimbursed by the payer.
- APC Validation: Ambulatory Payment Classification Validation program detects inappropriately coded claims that have already received APC payments. These most frequently occur because of CCI violations, incorrect modifier usage, and lack of relevant experience and knowledge in LMRP and LCD guidelines.
- In-patient coding expertise
- Clients achieve ROI exceeding 250%
- Errors are found in over 95% of the claims audited
- Auditors are Nurse Practitioners with over 5 years of experience in analysis of ICD-9, CPT & HCPCs codes, applicable CMS coding guidelines &state and federal regulations related to billing and coding for services rendered in facilities.
- Expert manual review
- Certified coders (CPC & CCS) for in-depth Chart Reviews.
- Part C (HCC) Coding – RADV-focused yearly capture or encounter-based.
- Claims Data Validation.
- Suspect Reporting: Inferred/deduced diagnosis from clinical cues.
- Others : Provider calling, Record Indexing , Date Stamping, Faxing.
- Impeccable track record & proven expertise for seven consecutive years.
- 3 M+ charts serviced in CY14.
- Nimble enough to adjust to your demands with in 60 days.
- Dedicated project management liaison.
- Detailed weekly reporting & audit.
- Year-round continuing education for our coders.