ikaD4C

Improve Care Coordination For Medicare Beneficiaries While Improving Reimbursement Accuracy

ikaD4C (Diagnosis for Care) uses a guided coding model to enhance the ability of physicians, certified coders or medical record reviewers to ensure the accuracy of diagnosis for Medicare beneficiaries, resulting in faster enrollment in the right care management programs for beneficiaries and optimized Medicare reimbursements for health plans, among other benefits.

Improving the Accuracy of Diagnostic Coding

ikaD4C begins creating efficiencies immediately by using clinically based algorithms to prioritize health plan members who are most likely to have chronic conditions that have not been coded to the specificity that the HCC model and care management criteria require. Using this prioritization queue, health plan staff can triage members for additional evaluation, medical documentation and coding. Members can also be proactively identified during eligibility determination.

Then, physicians, certified coders or medical record reviewers can follow straightforward decision trees and prompts to ensure all relevant diagnostic information is documented. Through this guided analysis, the accuracy of diagnosis is improved, which helps ensure members are in the right HCC category. In most cases, this will mean coding with greater specificity.

From this solid diagnostic foundation, members can more quickly be assigned to the optimal case management program and care plan for careful monitoring of their conditions, improving the quality of care while minimizing avoidable medical costs. Guided analysis also ensures that the health plan will report complete and specific diagnostic information to CMS, resulting in the appropriate HCC assignment and reimbursement.

Finally, ikaD4C delivers comprehensive tools to facilitate Risk Adjustment Payment System (RAPS) development, submission and return-file management, as well as sophisticated reporting functionality to not only determine return on investment but also support CMS compliance activities.

Comprehensive Identification, Workflow, Data Exchange and Care Coordination Capabilities

Key features of ikaD4C include the following:

• Identification and prioritization of the patient population
  
  
  • Retrospectively identifies potential candidates for enhanced diagnosis and care management using all available historical data: medical and pharmacy claims, lab and radiology results, and health risk assessments 
     
  • Prospectively identifies candidates prior to or at the provider encounter, so providers can immediately act on the information before a patient leaves the office
     
• Step-by-step guided coding for enhanced diagnosis
  
  
  • Populates a daily work queue with a list of potential candidates for review by physicians, certified coders or medical record reviewers
     
  • Guides physicians, certified coders or medical record reviewers through a step-by-step process to determine whether an enhanced diagnosis is appropriate, including the use of evidence-based criteria 
     
  • Allows physicians, certified coders and medical record reviewers to upload medical records to support an enhanced diagnosis 
     
  • Allows multiple levels of diagnosis and multiple diagnosis codes
     
• RAPS development and submission
  
  
  • Periodically generates RAPS files and facilitates submission to CMS
     
  • Analyzes RAPS return files and provides comprehensive workflow management tools 
     
  • Reconciles CMS payments with projected payments for each member 
     
  • Supports Risk Adjustment Data Validation (RADV) audits 
     
• Care coordination
  
  
  • Assigns enhanced care plans to members identified with chronic conditions 
     
  • Generates alerts to case managers when members are identified as having additional conditions and new care plans 
     
  • Provides care managers with comprehensive workflow tools, such as personal health records (PHRs), customizable flags/alerts, scheduling and data sharing capabilities, and the ability to track progress toward goals 
     
  • Provides continuity of care support by identifying candidates with chronic conditions whose diagnoses were not reported in the previous reporting period
     
• Reporting/Compliance
  
  
  • Reveals at a glance the before-and-after impacts of employing ikaD4C
     
  • Includes financial, productivity, compliance and actuarial reporting tools
     
  • Delivers tailored information by plan, county, product and provider, including the ability to drill down to the member level for  specific details

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