With the CMS RADV Final Rule and Final Rate Notice issued earlier this year, health plans are adjusting to the new coding guidelines and increased regulatory scrutiny over their risk adjustment activities. How can plans adhere to the new guidelines and maximize plan performance?
One way is through provider-centric risk adjustment practices. Putting providers at the center of the process and giving them the right resources helps optimize risk adjustment and quality performance. Provider centricity increases both provider and patient satisfaction because care can be better coordinated and care gap closure increased.
Bright Spots in Healthcare, moderated by host Eric Glazer, assembled an all-star panel well versed in risk adjustment to share best practices to drive strong performance in this changing environment:
- Colleen Gianatasio, director, clinical documentation integrity and coding compliance, CDPHP
- Michelle Illitch, vice president of network solutions and value-based programming, Priority Health
- Gregg Kimmer, president and CEO, ATRIO Health Plans
- Hassan Rifaat, MD, CEO, Vatica Health
- Frank Shipp, executive director, Johns Hopkins Clinical Alliance
Watch the webinar to get the full story, but in the meantime, here are key pieces of advice from the panel:
Develop workflows to minimize impact on provider productivity
Risk adjustment can be a heavy lift for provider groups of any size according to Frank Shipp, who offered the provider’s point of view on the panel. Physician buy-in is the first step. Instill confidence by ensuring a seamless workflow, decreasing administrative burden, and reducing compliance exposure via education and regular feedback on the appropriateness and accuracy of their coding documentation. For minimal impact on workflows and provider productivity, assess your EMR capabilities and load as much data into the EMR as possible. Payer data is also helpful. At Johns Hopkins, payer data is loaded into the EMR. Credentialled coders conduct pre-chart reviews to “set the table” for the visit. This helps build trust and credibility. Shipp recommends identifying physician champions to support your program. These are often early adopters with an interest in risk adjustment.
View risk adjustment as a clinical function, not a revenue function
ATRIO’s Gregg Kimmer sees risk adjustment as a clinical function, rather than a revenue function. Because Medicare Advantage has no medical underwriting, knowing the acuity of your members early is important. That requires support from providers who maintain a treasure trove of invaluable clinical information. Develop a framework so your providers can document to the highest level of specificity and give payers the most accurate picture possible. Create a partnership where both parties win. Support providers before, during and after the encounter. Offer resources and solutions that allow physicians to work at the top of their license.
The best place for complete and accurate coding is with the PCP
Make sure the process fits into the provider’s workflow and minimizes time required and abrasion, advised Hass Rifaat. The media has alerted providers to the heightened liability associated with faulty risk adjustment initiatives. Therefore, payers need to educate and reassure providers about how risk adjustment works and how to mitigate fines and penalties. “A combination of technology, people and data works best to help PCPs improve accurate and compliant risk adjustment coding,” Rifaat noted. Provider organizations vary; you’ll need to offer different workflows and flexible options to accommodate provider preferences. One vital component that’s often overlooked is compensation. Share incentives with treating providers and their staff. Leverage the entire PCP staff to complete coding and documentation, including mid-level providers.
Take advantage of the EMR
Michelle Illitch represented Priority Health, the third largest provider-owned plan in the country. Illitch noted that while technology is key, how the technology is implemented and utilized is critical. She pointed out that although the EMR is not ideal for documentation, payers who access the EMR directly can avoid asking for charts and obtain the info they need. The payer can also handle much of the pre-visit work for the provider and act as a planning resource, but it’s critical that the data is accurate. “If you give providers inaccurate info for a patient, the damage is irreparable,” she noted.
Ensure integrity of the data for the PCP
CDPHP has built their own clinical documentation integrity program that benefits the health plan and its providers with timely, actionable and trustworthy data. “Our program unites people, process and technology,” Colleen Gianatasio noted. CDPHP gives providers a curated list of information to review after the visit, with a full circle clinical data integrity process, including chart review after the visit. The plan continues to improve the data and analytics. For example, the plan has separate HEDIS and risk adjustment teams. The teams have been cross trained for better coordination and collaboration with providers.
The role of member retention in risk adjustment
Too often, plans don’t consider the importance of member retention in their risk adjustment programs, according to Gregg Kimmer. If plans can’t retain their members, they won’t reap the benefits from the risk adjustment and gap closure work they are doing today. The industry standard for voluntary disenrollment is 5 – 8%. ATRIO keeps disenrollment rates below the industry average with a constant focus on member experience and satisfaction.
Does it really work?
Hass Rifaat has seen from experience that a provider-friendly solution that compensates providers for their time and reduces their burden with dedicated resources can be successful. Offer a payer-agnostic solution that providers can use at the end of the appointment, during lunch or after office hours. Vatica Health has found that approximately 50% of PCPs want the solution in their EMR. The other half prefer a separate solution they can do in batches after the patient encounter. Rifaat called out a common misperception that risk adjustment is all about making money for the payer. It’s helpful to educate providers about the Affordable Care Act guardrails for medical loss ratios. At least 85 cents of every premium dollar must be used for members’ medical care.
He offered a case study with a regional plan in the Northeast which made its RA solution mandatory for participating providers. After three years, 70% of eligible members had an annual visit to gather info for risk adjustment. The plan increased its premium revenue by 15%, resulting in more market-competitive products. That drove more payers to adopt the risk adjustment solution; 80% of MA lives are covered by the solution with 70% of all PCPs participating. Importantly, the plan saw six Star measures move from less than 4 stars to more than 4 stars in one year, which are associated with better patient outcomes.
Bring back the joy
Priority Health Plan strives to be a catalyst for pre-visit planning, according to Michelle Illitch. This includes rich claims feeds provided via technology in a smooth, consistent process. Priority recognizes that providers don’t think about “lines of business” like payers do. They scrub data so the provider’s workflow reflects patients who need care the most, regardless of line of business.
Illitch noted that providers “feel beaten up by health plans.” She recommended keeping the Quadruple Aim at the forefront of what you do. Don’t forget about the provider experience. Payers can help bring back the joy of medicine for providers.
How Vatica Health can help
The Vatica Health solution directly supports many of the recommendations made by the experts on the webinar. Vatica Health is the #1 ranked PCP-centric risk adjustment and quality-of-care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge technology, Vatica increases patient engagement and wellness, improves coding accuracy and completeness, identifies and closes gaps in care, and enhances communication and collaboration between providers and health plans. The company’s unique solution helps providers, health plans and patients achieve better outcomes, together. With the Vatica team providing the extra resources needed for complete, compliant coding and documentation, physician participation is easier to enlist and sustain. To learn more, visit https://vaticahealth.com/.
