Why Medicare Advantage Plans and ACOs Need Experienced Vendors to Prepare for CMS-HCC Version 28

Medicare Advantage (MA) plans and Accountable Care Organizations (ACOs) should be reevaluating their vendor strategy in light of coming changes. 

This is largely because of a new version of the Hierarchical Condition Category (CMS-HCC) risk adjustment model that CMS released in 2023. It includes changes that will enhance the value of partnering with an experienced vendor for in-depth retrospective and concurrent risk adjustment reviews. Leaders at these organizations will benefit from taking the time to review the information below and use it to fuel their strategy around risk adjustment coding and HCC medical coding

Coming Changes Affecting Risk Adjustment Coding
CMS-HCC version 28 brings with it changes that should move leaders at ACOs and MCOs to review their risk adjustment strategy [1]. 

The revisions include technical updates including updated data years for calibration and also an updated denominator year for calculating the average per capita expenditures predicted. This means that the revised risk adjustment model will involve changes including: 

  • HCC names and numbers 
  • Adding 29 new HCCs
  • HCC mapping
  • Coefficient HCC values
  • 2,294 diagnosis codes were removed that previously mapped to an HCC 
  • 268 diagnosis codes were added that previously did not map to an HCC 

Impact on Patients
ACOs will need to pay particular attention to how this new version impacts them since they could be put at a disadvantage, especially those that have a higher proportion of patients with conditions that are weighted lower under V28 than V24. ACO leaders should know that in extreme cases, V28 drops some conditions entirely.

Why MA Plans and ACOs Should use Experienced Vendors
The complexity of these changes will be too much for many MA plans and ACOs to handle effectively. This means that a vendor experienced in risk adjustment coding can be a valuable asset in navigating this change. Here are some of the ways an experienced vendor can help.

Maintaining effective management of risk adjustment programs
Your risk adjustment program should keep up with, and even get ahead of changes like these. You should be prioritizing comprehensive risk adjustment documentation to paint a holistic view of patient health, all to optimize care plan creation, improve outcomes, support cost reduction, and maximize reimbursement. 

This, though, requires staff and tactics that are continuously trained and updated to keep up with changes, meaning that the resources needed to achieve this internally can be extensive, as well as a drain on management. 

Supporting Coding Quality
Quality is a critical foundation of risk adjustment coding and HCC medical coding. HCC models are advanced risk-adjustment models and can be incredibly complex, requiring highly skilled coders who ensure complete documentation and assign appropriate diagnosis codes if conditions meet the TAMPER or MEAT criteria. 

Coding talent is in a shortage right now and experienced coders are retiring, meaning higher costs in acquisition and retention of this skill set. 

Keeping Costs Low Amid Change
Change can be expensive. Between training, candidate acquisition, and even planning time of your managers, your costs in adapting and maintaining your risk adjustment coding program can quickly begin to creep up. At the same time, simple missteps can mean lost revenue and complexity that could have been avoided. In many cases, the cost of a vendor can be lower than the total cost of trying to navigate change alone, especially when opportunity cost is factored in. 

Maintaining Healthy RAF Scores
CMS has already acknowledged that the changes to this rule could affect beneficiary risk scores even if a patient’s health status is unchanged. This means that your RAF scores could deteriorate in ways you haven’t encountered before, causing severe financial impact. For example, type 2 diabetes mellitus patients without complications will see a slightly higher coefficient in V28, resulting overall in a serious reduction in the score for patients with acute or chronic complications. 

Getting ahead of future impact to RAF scores through risk adjustment reviews
Retrospective and concurrent risk adjustment reviews are a reliable way to assess the level of risk associated with a patient’s health and determine a list of potential HCC diagnosis codes that should be considered during a future encounter. 

To support organizations like yours in their risk adjustment coding efforts, we offer comprehensive services including HCC medical coding and risk adjustment reviews (concurrent and retrospective) to help you improve clinical documentation and coding accuracy. To learn how you can leverage our experience as a risk adjustment coding vendor, we encourage you to contact us today with any questions.

[1] AAPC, “Get Ready for CMS-HCC V28,” 30 June 2023. Available: https://www.aapc.com/blog/88300-get-ready-for-cms-hcc-v28/.

Medical Billing Predictions for 2024: The Weather is Finally Changing

Medical providers should be doing everything they can to get in front of the medical billing changes that are coming next year – and this starts with understanding what’s in the forecast for medical billing and medical billing services

Some of these predictions have been talked about for years, but because of changes brought about by COVID, staffing shortages, and increased complexity in medical billing and coding, they’re primed to begin to take real hold in 2024. Here are the three main factors I see shifting the medical billing landscape over the next year. 

Value-based care will increase the value of accuracy.
Value-based care has been slow to take hold but 2024 promises some changes that I believe will genuinely turn the tide. This is because of two initiatives that are set to launch next year. 

First, there’s the Guiding an Improved Dementia Experience (GUIDE) Model, an effort to improve the quality of life for patients with dementia, reduce the strain on caregivers, and help people remain in their homes. CMS is testing alternative payment for participants and the implications for care coordination and management as well as home health care could be significant. 

The second and possibly more impactful is the Making Care Primary (MCP) model. This voluntary model was announced this year and will be launching in eight states in 2024. This model could signal a new phase in adoption of value-based care since it is open to primary care physicians who don’t have experience in these types of payment models.

Recent changes will increase the ROI of outsourcing.
2024 will be a year where providers who understand the value of outsourcing will see increasing return on their investment. This is largely because of steadily increasing complexity of medical billing and coding

For example, consider that next year, the new version of the CMS’ Hierarchical Condition Category (CMS-HCC) risk adjustment model is scheduled to roll out. This new model adds almost 30 payment HCCs, changes the names of others, and shifts mapping among other changes. This level of complexity means that providers who try to navigate medical billing and coding alone without evaluating the potential of partnership in their medical billing service will be at a distinct disadvantage. 

Price transparency will increase the value of excellence in billing.
Patient expectations in billing have increased over the years, but with surprise billing legislation steadily taking hold, awareness of the importance of a positive billing experience is only increasing. 

This means that patients are talking and that providers who prioritize investment in becoming a center of excellence in billing will be able to differentiate themselves from their competitors. 

To learn more about how to prepare for a future where a medical billing services partner will be an advantage, I invite you to visit us.


Hemant Apte, Chief Executive Officer in

Hemant Apte, Founder & Chief Executive Officer of 3Gen Consulting, is a seasoned executive leader with deep domain expertise in US healthcare management practices. He founded 3Gen Consulting in 2006 and has been instrumental in offering thought leadership to his clients and providing services and solutions that are unique in the market.

The Helping Kids Cope Act Means a Fresh Look at Pediatric Billing and Working with Pediatric Medical Billing Companies

Finding new opportunities for pediatric billing is critical to maintaining the health of pediatric medical practices, and new legislation might be a change that aligns with the health of the children and families you care for. As you review the act, look for opportunities to expand pediatric medical billing and coding services

Understanding the Helping Kids Cope Act
The Helping Kids Cope Act (H.R. 2412) is bipartisan legislation designed to support the pediatric mental health workforce and give kids better access to the full continuum of mental health care. It does this by establishing new grant programs at the Health Resources and Services Administration (HRSA) for urgent needs for pediatric mental and behavioral healthcare. The grants take on the task of [1]:

  • Improving children’s access to support and community-based services. This happens through the strengthening of community-based pediatric mental health services, enabling pediatric care communities to implement and develop the new policies and programs that meet the unique mental and behavioral health needs of their patients. 
  • Expanding and enhancing the pediatric mental health workforce. Through the expansion of mental and behavioral health training, care communities will see an increased capacity of the current pediatric health workforce and support for recruitment and training of new pediatric mental health professionals. 
  • Investing in critical pediatric mental health infrastructure. When critical pediatric mental health infrastructures are expanded, the country will see improvement in the national capacity to deliver the best care possible for the children who have more intensive needs. These include inpatient psychiatric care, as well as step-down care like day programs and intensive outpatient services. 


How Pediatric Providers Should Respond
Anyone responsible for pediatric medical billing and coding services should look at this as an opportunity. 

Pediatricians are often the sole source of care for kids with mental health issues. This means that pediatricians are increasingly stepping up as mental health care providers. And pediatricians have been doing a good job. Research has found that when a pediatrician prescribed medication for a child who has depression or anxiety, it was generally done appropriately. But only one of out three children who were prescribed medication were also referred to a therapist [2]. 

This reveals that there is a gap in pediatric mental health care – and one that can be addressed by providers who are willing to expand the services they offer. These providers should consider this when looking for additional sources of revenue – the avenues opened up by the Helping Kids Cope Act mean the potential for new service lines and potentially the opportunity to leverage the help of pediatric medical billing companies to make sure your revenue cycle stays as healthy as possible. 

Consider the idea that, if children are in a position where they warrant medication, they should also be receiving other services. Eric Butter, chief of psychology at Nationwide Children’s Hospital in Columbus, Ohio emphasizes the fact that children who are given medication should also be receiving some form of counseling, saying that “a pill never taught a kid how to cope better.” Only a minority of children appear to be referred to a therapist, largely because of the lack of mental health specialists available. 

For pediatricians, this means an opportunity to consider offering billable services by bringing on providers such as psychologists, psychiatrists and other mental health care providers into their practices. Pediatricians have an amazing amount of leverage here in encouraging the use of any services they do decide to add on since families are leaning on them for guidance in navigating mental health issues. 

How Pediatricians Can Move Forward
It’s important to understand the services you might be adding. Mental health issues are prevalent in patients under the age of 18 [3]:

  • Over half of children have some type of disorder
  • Almost 20% have a specific phobia
  • Depression affects 18.6%
  • 12.6% are diagnosed with oppositional defiant disorder
  • ADHD affects 8.1%

Many pediatricians and pediatric trainees feel that they are not prepared to address these behavioral and mental health problems – which is exactly why expanding the services you offer and working with pediatric medical billing companies can be a win-win for your patients and your financial health. 

Improving Pediatric Medical Billing and Coding Services
As awareness of the resources available to children spreads, expect to see parents pushing for more access to mental and behavioral healthcare. 

There will be an increase in use of services from psychiatrists, psychologists, therapists, counselors and other types of mental health professionals, and you do not want to wait to figure out your strategy as things shift. Know that your parents will be asking questions about where they can access the best care for their children, and providers who offer these services within one practice will have a competitive advantage over other pediatricians. You should anticipate that some parents will be open to switching providers for the smoothest mental health experience possible for their children, giving preference to providers who offer more services in one practice. 

This means now is the time to lay out the services you might want to offer and figure out how they could increase your cash flows. Keep in mind that bringing on any of these services can put extra pressure on your revenue cycle, which is why you should also be considering working with pediatric medical billing companies to ensure the smoothest possible transition for your staff and your patients. 

If you are looking for options in pediatric medical billing companies, contact us today so we can help you formulate a revenue cycle strategy that aligns with your behavioral and mental health planning for the future.

[1] Children’s Hospital Association, “Bipartisan Legislation Would Invest in Children’s Mental Health Care and Workforce,” 24 May 2023. Available: https://www.childrenshospitals.org/content/public-policy/policy-position/helping-kids-cope-act.
[2] A. Norton, “For Kids With Mental Health Issues, Pediatricians Are Often Only Source for Care,” HealthDay, 17 April 2023. Available: https://www.usnews.com/news/health-news/articles/2023-04-17/for-kids-with-mental-health-issues-pediatricians-are-often-only-source-for-care#:~:text=%22Pediatricians%20can%20effectively%20identify%20mental,be%20therapists%2C%20Butter%20pointed%20out.
[3] The American Board of Pediatrics, “Behavioral and Mental Health,” 2023. Available: https://www.abp.org/foundation/behavioral-mental-health.

What the Texas Itemized Bill Law Means for Physician Billing Services

“As goes Texas, so goes the nation”. This saying is something anyone responsible for physician billing services should keep in mind when considering the impact of the Texas Medical Billing law. While the bill targets “healthcare facilities”, providers at all levels should pay attention – this type of legislation signals a shift in demands around the patient experience, which can easily influence the entire provider community.

The law ultimately puts providers under increasing pressure to optimize the efficiency of their billing processes, possibly incorporating the use of physician billing companies to quickly comply with new emerging standards. Revenue cycle leaders in states across the country will benefit from understanding the bill and the steps they can take to get ahead of similar legislation and sentiments in their home territory. 

An Update to Texas Medical Billing and Physician Billing Services
Texas Senate Bill 490 was signed into law in May of 2023 and took effect on September 1. It requires that patients be provided an itemized bill when they’re billed for medical services. Here’s how the bill plays out [1]:

  • Patients must be provided with an itemized bill, which can be either electronic or paper, outlining the cost of all services and supplies used during the provider visit.
  • The provider must submit the itemized bill to the patient within 30 days after the final payment is received from insurance carriers for any services or supplies.
  • Descriptions must use plain language for each distinct service or supply that was provided.
  • Bills must include all charges and billing codes that were submitted to a third party as well as the corresponding reimbursement from that third party.
  • The bill must include a calculation of the amount the provider claims is due from the patient for each supply or service provided.

An additional requirement from the legislation is what has so much potential to change patient expectations of provider billing practices – the bill entitles patients to receive an updated itemized bill by request at any time. Providers also will not be allowed to pursue debt collection against a patient for any service or supply unless they’ve met the requirements of the bill. 

The law allows for disciplinary actions against offenders, pushing providers to work with vendors to implement the system changes needed to create statements with all the required data points. It is also recommended that providers review their patient portals to decide whether it can be used to send itemized bills since this is allowed under the law. Providers will also be responsible for occasional testing to verify that the proper data is being included in the itemized bill, and also that the information is readable and understandable by patients. 

This bill does also create some complexity around patient liability. It doesn’t prohibit pre-service or time of service payments, which means portions are collected without sending an invoice. However, if insurance determines that liability is greater than what was collected, this must also be reflected in the itemized statement. This requirement means that providers will need to review their patient scheduling and registration processes for accuracy of estimations and pre-service and time of service payment policies if they would like to collect greater portions of liability before or at the time of service. 

Getting Ahead of the Trend
Anyone in charge of physician billing services should read these changes as a shift not just in legislation, but in the expectations of patients. They should be proactive in getting in front of this change, even if legislation isn’t immediately pending in their state. Here are a few tips to move forward in your physician billing services and provider itemized bills that improve the patient experience. 

Evaluate Current Practices in Physician Billing Services
Most importantly, look at your current practices. You’ll be looking at questions such as how often patients are requesting itemized bills now, or how often they’re confused about what they’re being sent. This could be the bills themselves or even simply the language used. You’ll want to look for opportunities in your processes to better inform patients and help them best understand their obligations. If you see any glaring holes, you should consider looking into physician billing companies

Look at Staffing
Helping patients better understand their bills will require a review of your staffing. More detailed bills not only require changes in how your billers work, but could also result in increased demands on office staff in handling calls from patients with questions. This could be an opportunity to contact physician billing companies to see who can help you evaluate and estimate your staffing needs. 

Decide on Your Metrics
The right metrics will be critical in determining whether your efforts to improve the patient experience through more detailed and informative billing are effective. Keep a close eye on cash flows and collections, as well as self-pay KPIs where applicable. You’ll also need to monitor metrics around data governance and data quality.

Consider Outsourcing Physician Billing Services
Many providers will find that the easiest way to get ahead of this trend in itemized billing is to work with physician billing companies. These services can provide you with access to a better and more consistent billing experience for your patients without the pressures of disrupting your in-house team. 

To learn how you can get started on that process today, contact us here


[1] S. Smith, “Texas Medical Billing Transparency Law Takes Effect Sept. 1,” Forvis, LLP, 20 July 2023. Available: https://www.forvis.com/alert/2023/07/texas-medical-billing-transparency-law-takes-effect-sept-1#:~:text=In%20May%202023%2C%20Texas%20Gov,when%20billing%20for%20medical%20services..

Home Health Billing Fraud Study

Home Health Billing Fraud Study Sheds Light on Growing Problem

Providers who outsource home health billing see multiple benefits, but one of the most important is access to a tool in navigating home health billing fraud. 

Healthcare billing fraud is a pressing problem, and a recent study out of Dartmouth’s Geisel School of Medicine offers a deeper understanding of how home health billing fraud has spread in recent years [1]. 

Types of Billing Fraud
To best understand the results of the survey, it’s important to first understand the type of home health care billing fraud you might encounter [2]. 

Fraud in Billing for Non-Existent Services
This is one of the most common types of fraud to look out for. In this case, services are billed but never performed. It can involve extra services being added to a legitimate patient bill or a situation that is more extreme, where someone finds a patient’s name and insurance information and uses this to create a fraudulent bill with services that were never performed. 

Medical Necessity
Another common type of fraud involves a party billing for services that weren’t medically necessary. For example, a diagnosis code like hypertension or diabetes that might not justify home health care services. 

In home health billing, there are some services that are often performed together that should also be billed together. In some cases, charging for these services separately can result in higher rates of reimbursement. By breaking them up, a billing party can receive higher payments. 

Durable Medical Equipment
Durable medical equipment (DME) is also an area that’s at risk for billing fraud. This can include examples like orthotics, patient lifts, walkers, glucose meters, traction equipment, pressure mattresses, and crutches. 

Upcoding Billing Issues
This type of fraud is a misrepresentation of services where a provider falsifies a claim to get paid for services that reimburse at a higher rate. 

Home Health Care Billing Fraud Study Results
The Dartmouth study took on the work of examining the network structure of home health agencies (HHAs) to identify a set of characteristics that were shared across the regions where fraud was most common. These characteristics included: 

  • Sharing patients across multiple agencies
  • Higher rates of expenditures across hospital referral regions along with fast increases in rates
  • Significant growth in the number of HHAS
  • Whether or not a region attracted a Department of Justice anti-fraud office

There was also a peer effect between local agency billing, which suggested sharing fraudulent practices between these local agencies. 

Types of Fraudulent Behavior
The study documented the most common types of fraudulent behavior, including:

  • Owners of agencies billing for services that were unnecessary or nonexistent
  • Physician kickbacks
  • Recruiting for patients
  • Staffing groups that got patients referred to an agency
  • Cross-network sharing of patient IDs in HHAs owned by organized crime

Activity Has Been Increasing
The researchers found a notable increase in home health care activity over the period between 2002 and 2009 which corresponded with expenditures doubling from $14.9 billion to $33.7 billion. This increase was mostly concentrated in just a few hospital referral regions (HRRs) which supported their findings that the regions were also areas where the Department of Justice had set up local anti-fraud offices. 

As an example, the average home health care billing per enrollee (Medicare) in Miami, FL and McAllen, TX increased by $2,422 and $2,127 respectively. In other HRRs where the DOJ wasn’t targeting, the average increase was $289. Study Lead Author, James O’Malley explains the difference in expansion rates, “it more or less makes the argument that if the benefits exceed the risks in the eyes of the perpetrators, then it’s more likely that you’ll see this type of fraudulent behavior where people are willing to risk conviction, fines, and imprisonment to make larger profits.”

While the study stands on its own, one additional outcome has been the development of tools that could be useful in the future in identifying more issues of home health billing fraud. The index (BMIX) looks promising in predicting excessive billing behavior from HHAs in the future. This means that it could be valuable for approaches based on machine learning to address billing fraud. The study authors expressed excitement at the idea of the methods being used to create generalized and alternative versions for organizations responsible for policing billing in healthcare. They look forward to the chance that the tools might be used to prosecute more violators, earlier, before fraud escalates, potentially saving the healthcare system and tax payers money. 

If you’re looking for ways to build an approach to home health billing that removes some of the internal and local risk of fraud, outsourcing should be on your short list of considerations. Outsourcing can be a path to end-to-end monitoring of your billing processes, increased efficiency, and easier response to a fast-changing regulatory environment. To learn more about how our services align with your needs, contact us today

[1] O’Malley, et al., “The diffusion of health care fraud: A bipartite network analysis,” Social Science & Medicine, 2023.
[2] Law Offices Of Robert David Malove, “Types of Healthcare Billing Fraud,” 2023. Available: https://www.robertmalovelaw.com/library/types-of-healthcare-billing-fraud-.cfm.

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