The risk adjustment industry may have experienced more upheaval in 2023 than the prior five years combined. Major regulatory changes announced by CMS shook up the industry. Vatica Health covered the operational and financial impacts of the Final Rate Notice–moving from V24 to V28–as well as the changing regulatory environment created by the Risk Adjustment Data Validation (RADV) Final Rule. Vatica analyzed these significant developments and provided practical insights on how to navigate these choppy waters. We also covered topics to help providers cope with the challenging environment.
Regulatory activity
Vatica covered the RADV Final Rule and the CMS Final Rate Notice in this piece highlighting practical strategies to consider. We delved into the RADV Final Rule in this blog, offering tips for both payers and providers. The potential financial impact of the RADV rule is explored in this piece.
Payer and provider collaboration
Vatica has helped lead the industry towards greater collaboration between payers and providers to optimize compliant risk adjustment. Hear directly from payers and providers in these webinars:
Provider burnout continued to be a key issue in 2023. We provided tips for easing providers’ coding and documentation burdenshere. The impact of Social Determinants of Health and five ways providers can address them are explored in this blog.
How Vatica can help
Vatica 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/.
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 rankedPCP-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/.
By Brian Flower, vice president of client solutions, Vatica Health
On January 30, 2023, the Centers for Medicare and Medicaid Services (CMS) released the final rule on Risk Adjustment Data Validation (Final Rule). The rule includes several changes. The most consequential is the new RADV audit methodology used by CMS to address overpayments to Medicare Advantage plans based on the submission of unsupported risk-adjusting diagnosis codes. The final rule authorizes CMS to extrapolate RADV audit findings beginning with payment year 2018 (not 2011-2017 as originally proposed). The industry views the use of extrapolation as especially punitive because in the Final Rule, CMS also rejected the application of the FFS Adjuster to account for an allowable threshold of errors related to provider medical record documentation.
The financial implications of the Final Rule are significant. Prior to the Final Rule, repayment obligations were limited to errors found in a sample of a few hundred records. Under the Final Rule, that error would be applied across a broader population of the Medicare Advantage Organization’s contract. Recently, the Office of Inspector General (OIG) audited diagnosis codes submitted by a health plan for approximately 200 members. The OIG found a high percentage of codes were not supported in the medical record. This resulted in $480,000 in overpayments, though the health plan disputes the findings. The new extrapolation methodology would not apply in this instance because the alleged overpayments occurred in 2015 and 2016. If extrapolation did apply – instead of approximately $480,000 – the overpayments would result in an exponentially higher repayment amount of approximately $27 million.
What can we tell about the extrapolation method if we consider these figures with membership data of the MAO contract in question? Straight-line math indicates that for each dollar of overpayment identified in the RADV sample, there’s an additional $55 of overpayment under extrapolation.
We should be careful applying these assumptions to other populations, especially considering the highly targeted nature of this audit in question. The OIG targeted HCCs representing $695,000 in payments. Based on their review, 69% of those dollars could not be supported by documentation. However, what seems to be apparent is that an extrapolation methodology has been determined and, when applied, material payment modifications can result.
Conclusion
The financial implications for RADV error rates will no longer be limited in materiality to small sample populations. Extrapolated penalties will be significant and potentially catastrophic to payers as well as at-risk providers. CMS estimates that from 2023 through 2032, the agency will recover an extra $4.7 billion from insurers via the new audit methodology. Given this, at-risk entities should evaluate their current risk adjustment programs and focus on solutions that produce accurate and compliant yield. Programs should include a robust quality improvement process to validate coding and documentation prior to submission. Legacy programs, such as retrospective chart reviews and in-home assessments, should be augmented with a provider-centric approach. Leading plans recognize PCPs as partners in coding accuracy and complete documentation to mitigate the risks associated with the Final Rule and the overall increased scrutiny on risk adjustment compliance.
How Vatica Health can help
Vatica Health is the #1 ranked provider-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 facilitates the closure of care gaps, 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. Vatica Health is trusted by many of the leading health plans and thousands of providers nationwide. For more information, visit vaticahealth.com.
By Jamie Jenkins, PhD, MBA, CPHQ, quality of care director, Vatica Health
Advancing health equity is the first pillar of Centers of the Medicare and Medicaid Services’ (CMS) strategic plan. The Biden-Harris administration has committed to promoting racial equity through government programs focused on underserved communities. To that end, CMS’ 2023 Medicare Advantage Quality Rule released in April 2023 finalized the new Health Equity Index (HEI) for measuring how well Medicare Advantage and Part D plans manage at-risk populations.
What is the index?
The HEI will drive health plans to fully engage and take steps to address the social determinants of health (SDOH) which negatively impact health quality and outcomes.
CMS has defined HEI as an index or single score that encapsulates contract performance for plans whose enrollees face specific social risk factors. The index will use existing data to limit the number of members who are identified as vulnerable. Stratified plan members who receive a low-income subsidy, those with a disability and those who are dual eligible will be in the scoring pool. Health plans should begin analyzing their data and designing programs to support these members.
What are the goals?
The initial goal of HEI is to increase transparency and understanding of plan performance in addressing the needs of members facing social risks. First, the index will be used to identify populations with the greatest needs so that targeted assistance may be granted to communities and providers serving those communities.
Second, the HEI will allow beneficiaries to select plans based on performance on health equity measures. Third, the index would become part of the Star Ratings program which is used to incentivize health plans with bonuses to improve performance. Prior to this new approach, there were no targeted incentives to address disparities among a plan’s enrollees. The HEI would be an added layer encouraging investment in health equity initiatives for Part C and Part D Star Ratings.
Call to action
Health plans have time to begin examining their approaches. The baseline data for the initial calculation of the HEI will be based on calendar years 2024 and 2025. The performance reward will be included in the 2027 Star ratings year.
Health plans can start their data analysis by comparing contracts to one another. For example, plans may consider the variances between those populations receiving a low-income subsidy versus those who are not. Comparing groups will allow plans to determine where support is most needed.
Data collection is key
One of the five priorities outlined by CMS in the framework is expanding the collection and analysis of standardized reporting. The agency seeks comprehensive, interoperable and standardized individual-level demographic and SDOH data. With an increased understanding of members’ needs, CMS plans to leverage quality improvement and other tools to ensure all members have access to equitable care and coverage.
CMS notes that developments in health information technology have improved the ability to collect health data and measure disparities at the provider level. Vatica Health, for example, provides technology and dedicated clinicians to enable providers to efficiently capture more accurate and complete diagnostic coding and documentation both for risk adjustment and improving quality of care. Vatica’s team of nurses curates relevant clinical data from various sources and creates a pre-encounter provider notification to enable more comprehensive encounters. The notification lists medical conditions, unreconciled medications and targeted quality measures to help the provider efficiently address the patient’s needs during the visit. As part of this process, Vatica can collect race and ethnicity information as well, using CDC specifications.
In summary, this framework is the first step in CMS’ drive toward improving health equity. “Our goals for Medicare Advantage mirror our vision for CMS’ programs as a whole, which is to advance health equity; drive comprehensive, person-centered care; and promote affordability and the sustainability of the Medicare program,” said CMS Administrator Chiquita Brooks-LaSure.
How Vatica Health can help
If you are considering a partner to help improve your Star quality measure performance, consider Vatica Health. We are the #1 rated 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 facilitates the closure of care gaps 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.
By Steve Zuckerman, cofounder and chief strategy officer, Vatica Health
Over the last several months there have been dramatic regulatory changes that will have a significant impact on Medicare Advantage Organizations (MAOs). The Centers for Medicare and Medicaid Services (CMS) made sweeping changes to both the audit process and underlying risk adjustment model, based on concerns with coding of conditions that the government claims are not credible predictors of future expenditures. These changes are against the backdrop of a wave of lawsuits and reports by the Office of Inspector General (OIG), alleging billions in overpayments emanating from legacy risk adjustment models such as chart reviews and home assessments.
Risk adjustment is the foundation of Medicare Advantage (MA). It’s a necessary but complicated process that ensures at-risk entities have sufficient funding to provide the appropriate care and resources to members based on their clinical profiles. As membership in MAOs has steadily increased over the last decade, so have the costs, leading to recent reforms. The first blow occurred on January 30, 2023, when CMS released the final rule on Risk Adjustment Data Validation (RADV Final Rule). This rule authorizes CMS to extrapolate RADV audit findings across a health plan’s entire membership base. The practical effect is that audits will be more frequent, and the new extrapolation methodology will likely result in much more significant fines and penalties (CMS estimates it will collect $4.7 billion more from plans over the next 10 years).
The government’s next initiative to address coding errors and variations occurred on March 31, 2023, when CMS released the Calendar Year 2024 MA Capitation Rates and Part C and Part D Payment Policies (Final Rate Notice), which shifts diagnosis coding from ICD-9 to ICD-10 and removes over 2,000 codes from the Hierarchical Condition Categories (HCC) model. Despite a massive industry-wide lobbying effort from both payers and providers, the new risk adjustment model was adopted. However, CMS did agree to a phased-in approach over three years which represents a meaningful concession.
Finally, on March 27, 2023, a bipartisan senate bill was introduced by Sens. Bill Cassidy, R-Louisiana, and Jeff Merkley, D-Oregon, entitled the “No Unreasonable Payments, Coding or Diagnoses for the Elderly Act.” This bill seeks to exclude diagnoses from chart reviews and health risk assessments in the calculations of a patient’s risk score. While the bill is in the early stages of consideration, it is consistent with the prevailing perspective and momentum away from legacy models and toward involving treating providers in the risk adjustment process.
The phased-in approach under the Final Rate Notice gives MAOs an important opportunity to review their risk adjustment solutions to make sure they will be effective under the new regulatory landscape. Here are a few practical strategies to consider:
Provider-centricity will be more critical than ever. As we transition to value-based care, it is critical for payers and primary care physicians (PCPs) to work together to improve care, outcomes and costs. Accurate risk adjustment is essential to ensure appropriate care for MA patients, the fastest growing healthcare segment. Therefore, it stands to reason that payers and providers should collaborate on risk adjustment and quality initiatives. Further, given the loss of several valuable HCCs under the Final Rate Notice, it will be more important than ever to ensure the capture and clinical substantiation of all risk adjustable conditions. Legacy models are deficient, work around providers, disrupt continuity of care and don’t accompany patient care plans. A better approach is to empower the PCP with tools and resources to perform HCC coding because the PCP has an existing relationship with the patient, direct knowledge of the patient’s history, and real-time access to the patient’s medical records. Enhanced payer and provider collaboration in this regard can produce better clinical and financial performance.
Reevaluate chart reviews and home assessments. Chart reviews and home assessments that lack connectivity to the PCP and don’t impact care are being targeted by the Department of Justice, CMS and OIG. Both may become obsolete if the “No Upcode Bill” is ultimately passed. Lack of clinical oversight and perverse incentives within these legacy risk adjustment models create an environment ripe for error and malfeasance. Another major concern is that they are not coordinated with treating providers and therefore have minimal impact on improving overall population health and value-based care performance. Consider ways to coordinate your chart review and home assessment programs with in-office solutions to keep PCPs at the center of care.
Focus on accuracy. In light of the RADV Final Rule and the myriad of lawsuits and investigations, at-risk entities should invest in solutions that produce compliant yield. They should focus on improving accuracy and completeness of documentation and coding and include a QI process that reviews both additions and deletions to validate coding prior to submission. The shift to value-based care will put even more pressure on payers and providers to use compliance-centric solutions that are focused on improving the accuracy and completeness of diagnoses codes and documentation.
How Vatica Health can help
Vatica Health is the #1 rated 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 facilitates the closure of care gaps, and enhances communication and collaboration between providers and health plans. The company’s unique provider-centric solution is used prospectively at the point of care, giving the provider control and ensuring continuity of care. The solution helps providers, health plans and patients achieve better outcomes, together. Vatica Health is trusted by many of the leading health plans and thousands of providers nationwide. For more information, visit vaticahealth.com.
By Brian Flower, vice president of client solutions, Vatica Health
The Centers for Medicare and Medicaid Services (CMS) released on January 30 the long-awaited final rule on Risk Adjustment Data Validation (RADV). The rule includes two significant modifications to the RADV audit methodology used by CMS to address overpayments to Medicare Advantage plans based on the submission of unsupported risk-adjusting diagnosis codes. First, the final rule authorizes CMS to extrapolate RADV audit findings beginning with payment year 2018 (not 2011-2017 as originally proposed) but did not elaborate on the extrapolation methodology. Second, a fee-for-service (FFS) adjuster will not be applied to RADV audit results, which was previously leveraged as a method of normalizing Medicare Part C payment errors against fee-for-service Medicare.
Industry leaders and health plan advocates have expressed concerns. Matt Eyles, president and CEO of America’s Health Insurance Plans, said, “Our view remains unchanged: this rule is unlawful and fatally flawed, and it should have been withdrawn instead of finalized. The rule will hurt seniors, reduce benefits for those who choose MA, and yield fewer plan options in the future.”
Health plans had similar reactions. “While we all can agree that improvements can be made, the failure to adjust for the legitimate differences between Medicare Advantage and original Medicare will have a detrimental effect on the seniors and people with disabilities who rely on the Medicare Advantage program,” the BCBS Association said. “CMS should have implemented a narrower solution aimed at a few bad actors, but instead this overreaching regulation will raise costs, reduce choice and make it more difficult for seniors and those with disabilities to effectively manage their health.”
As analysis of the rule continues, here are a few insights and practical strategies we have shared with our payer and provider clients.
Assess your “thin HCC” risk Even while the focus remains on accurate submissions, some HCCs will be easier to substantiate than others in an audit. It is important to understand what percentage of your submissions and Risk Adjustment Factor share would qualify as “thin” (associated with only one or two encounters, especially if significant effort is required to obtain a valid medical record). Understanding your risk will inform decision making on remediation within and after a given measurement period, as well as financial planning.
Prioritize treating providers Invest in programs that inform treating providers and empower them to code directly and accurately in a consistent and submittable manner, in favor of downstream coder abstraction that is not associated with the patient’s care plan. Engaged providers will become better organic coders over time, and a structured process can ensure necessary supporting documentation is reliably collected. In addition, compliant conditions collected shortly after encounters are recognized earlier than retrospective coding, allowing plans to identify open revalidation candidates within, instead of after, the measurement period.
Anchor on primary care The clinical benefits of encouraging a strong patient-to-PCP relationship are largely understood. Build a risk adjustment strategy that recognizes PCPs as partners in accuracy and quality capture as well. PCPs are your starting lineup for long-term chronic care management, medication compliance, specialty referrals and testing needed to fully assess many HCCs.
Engage the member As scrutiny over coding escalates, payers and providers should collaborate on member engagement to ensure annual visits are performed so that chronic conditions can be properly managed, as well as documented. Medicare Annual Wellness Visits (AWVs) are a great opportunity to engage patients in preventive care. AWVs can also be used as a springboard to participate in health plan-sponsored programs designed to capture accurate clinical documentation and close risk and quality care gaps. This expanded scope, which Vatica Health has dubbed an “Enhanced Wellness Visit,” ensures appropriate care and reimbursement while enhancing performance under value-based care arrangements.
Focus on accuracy above all else The final rule can result in more severe penalties, as well as myriad legal actions against payers and providers relating to alleged improper practices focused on boosting risk scores and associated payments. In light of this, at-risk entities should evaluate the compliance (real and perceived) of their current risk adjustment solutions. Consider solutions that produce compliant yield, focus on improving accuracy and completeness of documentation and coding, and include a QI process to validate coding prior to submission.
How Vatica Health can help
Vatica Health is the leading provider-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 facilitates the closure of care gaps, 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. Vatica Health is trusted by many of the leading health plans and thousands of providers nationwide. For more information, visit https://www.vaticahealth.com/.
By Lindsay Dosen, senior vice president of legal and compliance, Vatica Health
As more physician groups move into value-based care (VBC), many are encountering risk adjustment compliance issues they aren’t prepared for. Some of these issues can have serious legal and financial consequences if left unchecked. Preparing for these issues will enable physician practices to successfully transition to, and thrive in, a VBC environment by reducing compliance risk, improving patient outcomes and boosting financial performance. This article focuses on three common VBC compliance risks that PCPs should be aware of—along with recommendations on how best to mitigate them.
Risk 1: Unsubstantiated HCC codes
With the traditional fee-for-service payment models that PCPs have historically operated under, health plans—not PCPs—have primarily focused on accurately capturing Hierarchical Condition Category (HCC) codes for purposes of risk adjustment. However, under VBC arrangements (depending on the type of gain-sharing relationship), PCPs must focus on accurately capturing and documenting HCC codes. Underreporting or missing codes could translate to lost revenue for the PCP. Overreporting or submitting HCC codes that are inaccurate or unsubstantiated could subject the PCP to legal liability and regulatory penalties.
While this has been a major issue for health plans in recent years, this is also becoming a significant compliance risk for PCPs, as regulatory agencies have increased scrutiny of the risk adjustment programs and activities of both health plans and healthcare providers. These regulatory actions often assert violations of the False Claims Act (FCA) based on the government’s position that the risk adjustment payments were artificially inflated due to inaccurate or unsubstantiated diagnoses codes. Violations of the FCA can result in multi-million-dollar fines, not to mention lasting damage to a physician group’s public image and reputation, even when the violations were committed in error and without intentional wrongdoing by the PCP.
Fortunately, there are ways PCPs can protect against this compliance risk. First, PCPs should avoid payment structures that base payment on either a higher number of codes or higher-value codes. These types of payment arrangements are construed by the Department of Justice (DOJ) as problematic because they incentivize over coding and upcoding. Second, PCPs should provide training that reinforces the importance of compliant and accurate coding and that educates their staff about the potential legal, regulatory and financial risks associated with submitting inaccurate or unsubstantiated codes. Last, PCPs should invest in compliance programs that review coding and documentation to ensure accuracy.
Risk 2: Improper medical record review and sign-off
Another common VBC compliance issue that PCPs face is medical record compliance. You would think that the Centers for Medicare and Medicaid Services (CMS) recommended medical record review and sign-off process would be simple and straightforward. And it is—but only if the right person is doing it.
CMS outlines specific requirements as it relates to medical record documentation and risk adjustment diagnosis codes. Submissions with documentation issues could impact the validity of the medical record in a Risk Adjustment Data Validation (RADV) audit, leading to a potential discrepancy for the audited CMS-HCC findings. For a diagnosis to be risk adjustment-eligible, it must result from a face-to-face encounter with an approved provider type. The medical record must have, among other things, a valid signature and credentials for the approved provider. For PCPs, that means not just anyone in the practice can sign off on a medical record. A CMS risk adjustment-approved physician must be present during the face-to-face encounter. The record must also be signed by the CMS risk adjustment-approved provider. Learn more here.
This is an issue that can be easily remedied with proper education and training. PCPs should take steps to make sure that their staff clearly understands the importance of following the CMS guidance related to medical record documentation for risk adjustment. PCPs and their teams should read and be familiar with these compliance guidelines and should develop and implement policies and procedures to ensure compliance.
Risk 3: Vendor non-compliance
A third VBC issue is the misconception that a PCP’s responsibility for compliance is limited to only activities within the practice. If a PCP is working with an outside vendor that is non-compliant, the PCP may also be held liable for the vendor’s compliance violations.
The best way to mitigate this risk is to vet prospective vendors thoroughly in advance to ensure they have a clean compliance record and a strong compliance program in place. When selecting a risk adjustment vendor, PCPs should conduct due diligence to include, without limitation, reviewing information about the vendor’s compliance and security programs, any applicable coding policies and procedures, mechanisms for reporting suspected fraud, waste and abuse, exclusion screening, and any prior enforcement or legal actions taken against the vendor. In addition, a thorough review should be completed of the vendor’s operations related to the services being provided, including coding. Finally, PCPs should be thoughtful when structuring any fee arrangements with the vendor so as not to encourage over coding or upcoding. Payments under the arrangement should be based on the scope and quality of the services performed, without fluctuation (including bonuses or penalties) tied to the value or volume of the diagnosis codes captured.
Final recommendation: appoint a compliance lead
These three issues are examples of the compliance risks that PCPs operating in VBC are faced with every day. However, they are also examples of how an effective compliance program can help PCPs successfully navigate these issues and substantially reduce risk in VBC arrangements. An important way to ensure the PCP has an effective compliance program is to appoint a compliance lead for the practice. The compliance lead should stay up to date on compliance requirements and guidelines, develop policies and procedures to ensure compliance, provide training, promote awareness, and monitor and enforce compliance within the organization. An effective compliance program, led by a person with knowledge and expertise related to the compliance risks and regulatory requirements that are applicable to VBC, can greatly mitigate the compliance and financial risks to the practice. With compliance adequately addressed, PCPs can focus on delivering efficient, high-quality care to patients, which leads to successful financial performance in a VBC arrangement.
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