Did you know that CMS now pays Medicare Advantage plans such as CareOregon Advantage based only on submitted diagnoses?

How it works
In the CMS payment model, higher payment flows to plans that have higher cost and higher risk members. The model used by Medicare, called CMS-HCC, uses a complex decision tree to classify all members into 70 categories, called HCCs. These categories use ICD9 combinations to predict future cost. For example, a male with heart disease, stroke, and cancer has (at least) three separate HCCs. When combined, the total cost is more than simply additive because some disease combinations interact. (Source: Risk Adjustment of Medicare Capitation Payments Using the CMS-HCC Model, Pope, Kautter, et al, Health Care Financing Review, Summer 2004, pg. 123)

What this means to providers
CareOregon Advantage pays providers a conversion factor based on submitted CPT and HCPCS codes. Payment does not change based on ICD9 coding. However, incomplete or inaccurate ICD9 coding could result in lower plan revenue, which then influences how much CareOregon Advantage can pay providers, portrayed in the diagram below.

What you can do
Place accurate and complete diagnosis codes on all your claim submissions! Make sure that you use the most specific diagnosis code available, and submit secondary and tertiary diagnosis codes when appropriate.