Medical Record Reviews Conducted
to Validate Medicare Risk Adjustment Data

The Centers for Medicare and Medicaid Services (CMS) conducted medical record reviews to validate the accuracy of the 2004 Medicare Advantage Risk Adjustment (MRA) data and payments. Humana was one of many Medicare Advantage (MA) organizations randomly selected by CMS to participate. The review process required Humana to submit appropriate medical records supporting 2004 Medicare claims and encounters. Specifically, the review sought to verify that the medical records supported the diagnosis associated with the Hierarchical Condition Category (HCC) noted by the physician on the claim or encounter.

The medical records collected included records from inpatient facilities, outpatient facilities and physicians. Humana would like to thank its network physicians and other providers for their efforts in submitting the medical records and complying with the new Medicare Risk Adjustment requirements.

In the new Medicare Risk Adjustment environment, it is critical to continue to code to the highest level of specificity and to record all diagnoses in the medical record. Humana has a number of resources available to help physicians understand and implement the HCC coding model. For more information, visit Humana’s Web site at www.humana.com. On the home page, click on “Providers” on the left side of the home page, and then click on “Provider Self-Service Center.” Then select “Health Plans and Products” on the left side of the page. Scroll down and select “Medicare Advantage” under Medicare/Seniors. Enter a ZIP code, and then select the appropriate Medicare Advantage plan from the drop-down menu. The page that follows includes links to more information on the CMS-HCC Medicare Risk Adjustment model and to a free MRA ICD-9 coding tool that can be downloaded to a personal computer or personal digital assistant (PDA).

Detailed information gathered during the data validation process is still under review. Humana will inform providers about the data validation results when they become available.