Hierarchical Condition Categories (HCC)model is used by the Center for Medicare and Medicaid Services (CMS) in order to track risk adjustment of the Medicare Advantage Program. There are many HCC categories that consist of specific diagnosis predetermined by CMS each year. The conditions must be coded properly in order to qualify in the appropriate category. The burden of properly reporting and documenting the condition falls directly on the provider.
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Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by health plans to measure the performance of each provider on important aspects of care and service. The categories used to measure the performance of each provider are predetermined every year by the National Committee for Quality Assurance (NCQA).
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SEPA has a staff that includes Registered Nurses and Certified Coders. They perform chart and claims audits to ensure that all conditions are documented and coded to the highest level of specificity.
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Recently primary care physicians have experienced annual reductions in payments while their cost of doing business has gone up an average of 3% annually. Maintaining high quality of care in this environment is challenging.
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In addition to physician and physician groups, Southeast Physician Associates provides MRA and HEDIS auditing services to health plans, staff-model medical centers and other MSOs and IPAs.