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Unlocking the mysteries within your CMS claim file

In a healthcare industry that is shifting from fee-for-service to value-based-care models, it’s increasingly important for practices to understand everything about their costs. To that end, Centers for Medicare and Medicaid Services (CMS) delivers a claim file to Accountable Care Organizations (ACOs).

Unfortunately, ACOs often don’t take full advantage of the intelligence available within the CMS claim file. But if ACOs can unlock these “mysteries” held within the file, they can reduce costs more quickly. Here are just a few examples:

Where do all my patients receive care?

Your CMS claim file can show you where your patients are actually receiving care. The answer may surprise you.

For example, we helped one of our ACO clients in the rural Midwest plot on a map where its patients were receiving care. As expected, patients received a lot of care in the surrounding counties. But unbeknownst to the physicians, patients received care in scattered locations all over the country.

To truly coordinate care, ACOs need to know when “snowbirds” are visiting specialists in Florida, for example. All of these episodes help give a more complete picture of a patient’s health risks.

Because CMS attributes these patients to us, we own their chronic care management, right?

Not necessarily. A recent blog post discussed the importance of accurately calculating the number of attributed lives.

But there is nothing that prevents another physician office from inviting your patient to be part of its Chronic Care Management program. Practices that are proactive in reaching out to patients could earn them as attributed lives over time.

So it’s important for practices to continue to engage their patients, to maintain that relationship and to better coordinate that patient’s care.

Are we coding our high-risk patients properly?

Proper diagnosis coding becomes increasingly important in a value-based-care model. CMS uses these codes to set its benchmark on how much it expects patients to cost over time. CMS actuaries will set a lower financial payment for a bunch of healthy patients than they will for a group of really sick patients with comorbidities.

Let’s say a physician examines a 70-year-old man with a sore throat. Turns out it’s a strep infection, and that’s how he codes the encounter. Now, let’s say that same patient also has hypertension, diabetes and is obese. If the physician fails to note these diagnoses, then CMS regards this patient as healthy, instead of the higher-risk (higher-cost) patient he actually is.

Coding practices can significantly alter the CMS perception – and therefore target benchmark – of how healthy or high-risk your patient population is. It’s important to get that right for an ACO to be successful clinically and financially.

The ultimate goal is coordinated care

Unlocking the mysteries of the CMS claim file can be frustrating if you don’t know how to use the guideposts. But the effort is worth it.

Looking at several CMS initiatives – whether it’s ACO, Comprehensive Primary Care Initiative (CPCI), Patient-Centered Medical Home (PCMH), or others – and they all point to one thing: coordinated care. Participating in these programs is all about stopping duplication of services, improving lives and outcomes.

We have healthcare economists and care managers that can help your practice uncover intelligence in your CMS file. To learn more, contact us .

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