When treating physicians incompletely document patient disease burden by undercoding or miscoding patient encounters, an expensive cycle of retrospective audit is required. ![]() Getting the coding and documentation right before claims submission with prospective review decreases the number of charts that need to be audited, saving organizations future administrative burden. The most obvious benefit of prospective review is enhanced revenue cycle management - preventing incorrect claims from going out in the first place reduces the chance of denials and results in quicker more accurate payments. The focus of retrospective review can then be narrowed down to ensuring compliance and verification of conditions reported on claims, rather than hunting through documentation to discover potential diagnoses. Prospective and retrospective risk adjustment are two sides of the same coin, and the efforts must be coordinated.īy investing in resources and incentives that encourage providers to document and code more accurately in the first place, there will be significantly less need for comprehensive retrospective reviews. Retrospective reviews remain necessary and important - the goal is not to cut out the retrospective process but rather to put an increased focus on strengthening prospective processes. But with the shift to value-based care, emphasis on early intervention and growing regulatory pressure to get coding and documentation right on initial claims, risk-based payer and provider organizations are increasingly incorporating prospective reviews into their workflows. Historically, Medicare Advantage Organizations (MAO’s) have relied on retrospective chart review as the primary method of discovering conditions that may not have been coded during the patient encounter.
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