As you may be aware, Medicare reimburses Commonwealth Care Alliance according to the chronic conditions of our members. To receive reimbursements, we must submit to Medicare diagnosis information extracted from provider claims, and complete an annual review of our primary care medical records.
 
It is vital that Commonwealth Care Alliance ensures accurate and thorough diagnosis coding to reflect the disease burden of our population. This not only ensures maximum reimbursement to better care for our members but it also enhances Commonwealth Care Alliance's chances of passing a Medicare audit of provider documentation. Medicare began auditing medical records of providers contracting with Medicare Advantage plans in 2009, looking for provider documentation to support the chronic conditions by which they reimburse health plans. To prepare for an audit, Commonwealth Care Alliance is conducting a sample audit of 100 members across multiple provider types to assess our strengths and areas for improvement in provider documentation. Sample audit results will be shared in May.
 
Commonwealth Care Alliance is currently evaluating our business strategy to ensure the success of our providers under Medicare's diagnosis-driven reimbursement model. One strategy will be to offer training on clinical code documentation for nurse practitioners and other interested parties at our primary care sites. We will be hiring an expert trainer to conduct the sessions, in addition, we have hired a nurse clinical coder who will act as an ongoing resource for our primary care sites. Subsequent primary care site newsletters and Small Dose communications will also feature coding tips.

Questions? Please contact Kara Curtis, Director of Strategic Business Initiatives and Compliance, at 617.426.0600 ext. 236 or kcurtis@commonwealthcare.org