It was obvious that HCCs would go in the same direction that DRGs did when MARSI started over 25 years ago… Lessons learned from DRGs would be applicable and beneficial. It was also obvious that Medicare Advantage was expanding. Add to that mixture the fact that, even to this day, physicians who are untrained in documentation and coding for risk adjustment are the ones assigning the codes. The codes have already been assigned by a physician, therefore, any review of that coding and documentation is auditing which is the reasoning behind the audit portion of the training.
In hospitals, with DRG’s, they stopped allowing physicians to weigh-in on the coding of charts over two decades ago because, revenue was dependent on good coding and physicians knew nothing about it, or at least knew very, very little.
Early in DRG auditing we found error rates of 20, 30 even 40%. That is now down to approximately 10%. The average value of an under code or over code is approximately $4000 in DRGs.
In Medicare Advantage, we see 40 to 80% error rates with provider groups that have not worked intently on improvement. Interestingly the average value change per record is approximately $6000. But we still let untrained physicians code the records.
It is only a matter of time before the risk adjustment industry recognizes that there needs to be an enormous increase in highly trained coder/auditors in HCCs. That’s what MARSI believed in 2008 and it appears to be coming true.