Category: Risk Adjustment

The RADV final rule – strategies for mitigating the impact

By Vatica Health | March 13, 2023 | Compliance, Risk Adjustment

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Insurance Plans, said, “Our view remains unchanged: this rule is unlawful and fatally flawed, and it should have been withdrawn instead of finalized.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.

  1. 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. 
  2. 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.
  3. 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.
  4. 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.
  5. 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/.

Elevating risk adjustment by activating physician participation

By Vatica Health | March 3, 2023 | Risk Adjustment

As the pandemic subsides, many PCP groups are seeking to restart or ramp up value-based care (VBC) initiatives that took a back seat to battling COVID for the past two years. The economic impact of COVID on PCPs heavily reliant on fee for service and the looming recession will only accelerate the transition to VBC. However, it does come at a time when many providers are short-staffed and feeling overwhelmed.

A recently-released three-year study by JAMA revealed that, between the fall of 2019 and early 2022, the percentage of healthcare workers who perceived emotional exhaustion in their workplace climate increased from 53.3% to 64.9%. The unfortunate reality is that many physicians are struggling with burnout which has been greatly exacerbated by the multi-year COVID crisis. Addressing this challenge requires collaboration and coordination of efforts among payers and providers.

How can care providers and payers work together to activate physician participation in this climate to improve diagnosis coding and documentation, close gaps in care, achieve better clinical and financial performance, and support VBC initiatives? Some answers were offered in a “Bright Spots in Healthcare” podcast.

Moderated by host Eric Glazer, the podcast offered the perspectives of a diverse, blue-ribbon panel of experts:

  • Jeslie Jacob, divisional vice president, provider analytics, reporting and connectivity, Blue Cross and Blue Shield of Illinois
  • Janie Reddy, DNP, FNP-BC, director of family medicine, CommuniCare Health Centers
  • Rebecca Welling, associate vice president, risk adjustment and coding, SelectHealth
  • Lisa Wigfield, RN, BSN, CCM, CRC, CDEO, clinical advisor, risk management, Priority Health
  • Hassan Rifaat, MD, CEO of Vatica Health

Watch the whole podcast to get the full story, but in the meantime, here are some key pieces of advice from the panel:

“The key is to bring the gaps in patient care into the workflow at the point of care.”

Successful VBC is built on data and analytics, but as Jeslie Jacob stressed, gaps in care must be visible at the clinician’s fingertips when interacting with the patient. Jacob emphasized the value of EMR integration and dashboards to ensure that clinicians have ready access to up-to-the-minute insights when they meet with patients.

“Capture as much as you can during the visit.”

Janie Reddy emphasized maximizing the opportunities presented by the office visit. “If a patient comes in for an acute visit – say, for a cough – we treat the cough, but we’re also looking to see if they’ve had their preventive screenings,” she said. “If they’re diabetic, have they had their A1Cs done for the year? We’re looking at the whole picture: all their quality metrics. It’s all embedded in data analytics and presented via dashboards that show us exactly what is outstanding for each patient.”

“It’s got to be documented to capture it.”

Data goes both ways, according to Lisa Wigfield. You’re not just using historical health data to inform the office visit; you’re also generating new, vital data during the visit. For that reason, she cited the importance of documenting everything, thoroughly and accurately. Wigfield mentioned how Priority has enhanced MA benefits and offers a “free to talk” visit that has no copay. The visit provides an opportunity for PCP and patient to talk about health. It’s a good way to address care gaps and discover new issues the PCP may not be aware of.

“Go from a physician-only approach to a team approach.”

Reddy is a firm believer in sharing the VBC workload among physicians and other staff so that the burden doesn’t fall disproportionately on physicians. There are several advantages to this. For one thing, it enables physicians to accomplish more during the time they have with patients. Secondly, it builds a sense of VBC ownership across the entire team. When everyone feels that they are being supported by their colleagues in making VBC work, the effort will be more sustainable. However, keep in mind that a successful team approach requires that each team member has a clear understanding of their role and responsibilities and the practice’s expectations of them.

“Make sure health plan incentive dollars flow down to the practice.”

Incentive dollars aren’t much of an incentive if the people earning them don’t receive them. That’s why Hassan Rifaat, MD, stressed that clinicians should be paid directly for the work they’re doing. He urges practices to “make sure money is flowing down into the practice, from providers to support staff; invest the time to figure out how to do that.” That tangible ROI for the team’s VBC efforts will help ensure their continued commitment. Dr. Rifaat also made a key point about the economics of VBC implementation: “The upfront costs of a VBC program are significant and it can take as long as two years for some of those investments to start generating positive cash flow,” he said. “Once it does, it’s self-funding. But until that happens, some form of subsidy can help providers make the investments needed to get their VBC program off the ground.”

“Be sure to include staff in the incentives.”

When it comes time to share incentives with staff members, PCPs have any number of ways to do it. Which is best? Rebecca Welling believes one effective way is to link specific incentive payments to the successful performance of specific tasks. “For example,” said Rebecca, “you could offer to pay your scheduling staff $25 for every one of these high-acuity patients they bring in.” The direct connection between task and reward can be a strong incentive.

“Take advantage of friendly competition.”

Don’t be reluctant to share provider performance data within your organization to spur friendly competition. Reddy said, “As clinicians, we have a competitive drive within ourselves, and this has really motivated us to push each other to deliver quality care to our patients.” Bottom line? Money isn’t the only incentive; competition can be a powerful tool, as well. To encourage competition, Dr. Reddy said “Dashboards are our friend.” Readily accessible and easy-to-read dashboards make it simple for physicians to compare their work with their peers’.

How Vatica Health can help

The Vatica Health solution directly supports many of the recommendations made by the experts on the podcast. Vatica Health is the leading PCP-centric risk adjustment and quality-of-care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge, 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 to get VBC off the ground and operating successfully, physician participation is easier to enlist and sustain. To learn more, visit https://vaticahealth.com/.

3 major PCP risks in VBC—and how to reduce them

By Vatica Health | December 1, 2022 | Compliance, Risk Adjustment, Value-Based Care

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.

In-home risk assessments are under fire

By Vatica Health | October 21, 2022 | Risk Adjustment

A message from our chief strategy officer and co-founder, Steve Zuckerman

On October 17, 2022, the United States filed a lawsuit against Cigna Corporation and its subsidiary Medicare Advantage Organizations, intervening on a lawsuit filed by a whistleblower several years earlier. The lawsuit seeks damages under the False Claims Act for Cigna’s alleged submission of invalid diagnoses codes for purposes of inflating risk adjustment revenue for its Medicare Advantage plan members. Health plans like Cigna are required to report patients’ diagnoses which are used to calculate “risk adjustment” payments to the plan based on demographic information and the health status of patients. Over the last few years, lawsuits against Medicare Advantage Organizations (MAO) have increased significantly, centering around what the government alleges are improper practices focusing on boosting risk scores and associated payments.

The government’s lawsuit against Cigna focuses on diagnosis codes submitted on forms completed by several home assessment vendors. The lawsuit alleges that these vendors did not properly validate the existence of the reported conditions. Further, the diagnoses were not supported by the minimal information contained in the vendors’ forms. The government identified a major flaw in the home assessment vendor process in that it failed to coordinate with the patient’s primary care physician (PCP) or account for the patient’s full medical history. Instead, the home assessment vendors relied on limited data provided by Cigna and self-reported patient information which created an incomplete picture. As a result, according to the government, Cigna was overpaid tens of millions of dollars in risk adjustment payments from the Centers for Medicare and Medicaid Services (CMS).

The government’s action against Cigna is the latest in a string of lawsuits and recent Office of Inspector General (OIG) reports claiming that MAOs have received billions in risk adjustment overpayments. A common theme in these cases and recent OIG reports is that home assessment vendors work around PCPs, instead of with them. Sending a clinician to a patient’s home, without any relationship with the patient or the PCP, has been increasingly scrutinized as it’s viewed as a method to simply improve risk score without improving patient care or outcomes. In fact, going back as early as 2014, in its 2015 Advance Notice Proposal, CMS suggested to “exclude for payment purposes diagnoses identified during at home visits that are not confirmed by a subsequent clinical encounter.”

The mounting scrutiny of home assessments has continued. In September 2021, the OIG issued a report regarding billions in alleged overpayments to MA plans. It specifically criticized home assessments, making the point that the failure to work alongside PCPs raises concerns about the quality-of-care coordination for these patients and the validity of diagnoses. These concerns are being exacerbated by fundamental flaws in the home assessment process, including the failure to consider pertinent patient information contained in PCPs’ electronic medical records and the lack of follow-up with the PCPs to ensure chronic conditions and care gaps identified during the assessment are being addressed.

Despite the flaws with home assessments that are not connected to PCPs, MAOs ultimately bear the responsibility. In our experience, MAOs do not intentionally misrepresent their population risk. They are simply relying on vendors employing legacy programs that have not evolved to meet the current regulatory environment. 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.

As the pioneer in physician-centric risk adjustment processes, Vatica has emphasized for over a decade the importance of including PCPs in the risk adjustment process. Instead of using third parties with no pre-existing relationship with the patient and no access to the underlying medical record, Vatica’s solution empowers PCPs to improve outcomes while easily completing HCC coding with the greatest level of accuracy and completeness. By pairing technology and dedicated clinical support at the point of care, Vatica enables PCPs to drive the most compliant and accurate risk adjustment results, close care gaps, and improve performance.

Physicians want resources to address SDOH: Here’s where to find them

By Vatica Health | August 18, 2022 | Provider, Risk Adjustment, Value-Based Care

Physicians are well aware of the impact created by social determinants of health (SDOH) and want to address these needs, as indicated in a recent survey. But many believe they can’t help their patients, due to:

  • Limited time to discuss SDOH during patient visits
  • Insufficient staff to direct patients to the appropriate resources
  • Existing payer requirements that take time
  • Lack of reimbursement for screening for SDOH
  • Unavailable, inadequate or difficult-to-access resources

The good news is that as the focus on SDOH grows, more resources than ever are available to help physicians, from community resources to health plan-sponsored programs to time-saving solutions.

Primary care physicians (PCPs) can take advantage of multiple resources from their health plans. In particular, Medicare Advantage plans are rapidly transitioning to value-based care, at the direction of CMS. As CMS moves to pay for quality rather quantity, the depth and breadth of payer-sponsored programs grows.

SDOH programs show measurable improvements

Anthem, for example, offers the Members Connect program to its Medicare Advantage members. The program addresses social isolation and loneliness to improve members’ overall health. It connects members to a community health worker who helps them find specific community resources they need. Volunteers act as social care partners or “phone pals” who call members weekly to check on them and provide a social connection.

The program gets accolades from members: 74 percent said they increased engagement in their health. Anthem’s claims data shows that participants reduced hospital admissions by 8 percent and ER visits by 43 percent.

Superior HealthPlan, based in Texas, offers a multitude of programs: housing assistance, an in-house network of community health workers to guide members, and a unique program that helps provide funding for hygiene closets. The plan partners with community organizations across the state to offer these hygiene closets with products needed to maintain a healthy, active life. At nearly all of the hygiene closets, specific dates are designated as “Superior Days,” where plan representatives join with other community partners to host events and provide direct resources for those who need them.

To learn about programs available to their patients, physicians and office managers can contact their health plans’ provider representatives or quality teams.

Time-saving solutions

Lack of time and insufficient staff to address SDOH were cited by survey respondents as well. Here, too, PCPs can look to their health plans. With the transition to value-based care, plans offer resources such as care managers who support patients with SDOH-related needs. PCPs should be aware of which health plans offer these services and refer patients for additional support.

Note that ICD-10-CM Z codes are available to report patients’ SDOH but are generally underutilized by PCPs. When PCPs use these codes to report SDOH, that information is passed to health plans through claims. Plans can use that information to enroll patients into their various SDOH programs, alleviating the burden for PCPs.

Likewise, as plans ask PCPs to document and code Medicare Advantage patients’ health status for accurate risk adjustment, they may offer additional resources to assist patients with identified needs. A number of national and regional plans partner with outside resources, such as Vatica Health. Vatica offers a PCP-centric risk adjustment and quality of care solution, which combines technology and clinical consultants at no cost to the practice. These specially trained clinicians serve as an extension of the practice. They review and curate all relevant health plan and EMR data. This information is used to create a pre-visit notification to help the PCP efficiently perform the visit, document patients’ health status and assist with care gap closure.

Vatica’s time-saving solution enables PCPs to increase use of preventive services and improve patient satisfaction with Vatica’s combination of technology and clinical support teams. When patients’ conditions are accurately reported to health plans, that ensures adequate financial resources are available through CMS. This can also result in the patient receiving additional services from the health plan to address chronic care needs, complex conditions and SDOH.

More resources benefit PCPs and patients

SDOH continues to get more visibility, and rightfully so. This is good news for PCPs. More resources from health plans, government-funded programs and community organizations can help PCPs address SDOH. Outcomes include healthier, more satisfied patients and easy-to-access resources that can help to address lack of clinical staffing and staff burnout.

Bridging the Quality Gap through Race and Ethnicity Reporting

By Vatica Health | April 20, 2022 | Provider, Risk Adjustment, Value-Based Care

As efforts continue to improve quality and reduce healthcare costs in the U.S., evidence shows that racial and ethnic health disparities have a significant negative impact. According to a report from the Commonwealth Fund, “Black and American Indian/Alaska Native (AIAN) people live fewer years, on average, than white people.” They are more likely to die from treatable conditions, to die during or after pregnancy and suffer serious pregnancy-related complications, and to lose children in infancy. Black and AIAN populations are also at higher risk for many chronic health conditions, ranging from diabetes to hypertension.  

The harsh reality of these health disparities was revealed by the COVID-19 pandemic and its disproportionate impact on people of color. Black, Hispanic and Asian populations in the U.S. have significantly higher infection rates, hospitalization, and death compared to white populations.  

The effect on the cost of healthcare is substantial. A recent Texas study showed that over the last six years, racial and ethnic health disparities in the state have resulted in $2.7 billion in excess medical spending and $5 billion in lost productivity.  

An important step to reducing disparities is efficiently collecting race and ethnicity data. This has proven to be a difficult task due to: 

  • The lack of standardized race and ethnicity categories 
  • Incomplete forms used to collect the data 
  • Electronic health records built without the ability to collect the information 
  • Discomfort of healthcare staff asking for information 
  • Few detailed descriptions for patients to accurately self-identify 
  • Patients may be reluctant to share this kind of information  

Additionally, social determinants of health (SDOH) have proven to be a significant source of disparity among racial and ethnic minorities. Using quality tools as a method for collecting data and advancing health equity has great potential to address the deeply rooted issues of SDOH. While some improvement has occurred, more work is needed.  

National Committee for Quality Assurance Strategies  

The National Committee for Quality Assurance (NCQA) compiles the Healthcare Effectiveness Data and Information Set (HEDIS). This provides quality results annually for more than 203 million people and 60 percent of the U.S. population. 

NCQA introduced a racial/diversity measure in 2015. But health plans struggled to obtain the needed data through member self-reporting, disease registries and other traditional means. NCQA’s 2019 records showed that approximately 76 percent of racial data and 94 percent of ethnicity data were incomplete for the commercial product line. Medicare plans demonstrated higher collection rates: 26 percent of racial data and 60 percent of ethnicity data is incomplete.  

The lack of completeness raised concerns about relying on traditional sources to accurately measure disparities in care. Without reliable data, identifying those with unmet needs is difficult. 

Improving Data Collection 

To increase collection of data from health plans, NCQA began requiring stratifications by race and ethnicity in 2021.  

NCQA started with five measures across key known disparities: colorectal cancer screening, controlling blood pressure, hemoglobin A1c control for patients with diabetes, prenatal and postpartum care, and child and adolescent well care visits.  

Race and ethnicity data on these measures help plans better understand member needs and provide services to address those needs. Plans can measure and track performance on disparities and implement data-driven approaches to close care gaps and improve outcomes in vulnerable communities, especially related to SDOH.  

Some plans are already working to close equity gaps. Centene Corporation was recently awarded the Innovation Award for Health Equity by NCQA. They implemented a data-driven approach focused on community disparities within markets. Improvements were seen in colorectal cancer screening rates for American Indian/Alaska Native members, increased rates of immunizations for Latino children and better maternal outcomes among Black mothers. 

Help is available to health plans seeking ways to reduce disparities of care among their membership. Vatica Health, for example, provides technology and dedicated clinicians to enable providers to efficiently capture more accurate and complete diagnostic coding and documentation for risk adjustment and improving quality of care. As part of this process, Vatica can collect race and ethnicity information using CDC specifications for the measures designated by NCQA. This helps Vatica clients meet NCQA requirements and collect the data needed to identify and reduce disparity gaps in care. 

Conclusion 

High quality, affordable healthcare for all isn’t possible without addressing disparities in our current system. Collecting race and ethnicity data is the first step toward developing effective solutions to address this complex challenge. While this is not a simple task, actions by NCQA and other stakeholders show potential. Collecting and using race and ethnicity data to identify disparities and factors that drive them is critical to achieving better healthcare for everyone. 

About Vatica Health  

Vatica Health deploys clinical nurses at the point of care, armed with powerful technology. Vatica’s solution accelerates the transformation to value-based care by helping providers, health plans, and patients work together to achieve better outcomes. Visit https://vaticahealth.com/ to learn more. 

Closing the Gap on Missed Medical Care

By Vatica Health | March 16, 2022 | Provider, Risk Adjustment, Value-Based Care

The COVID-19 pandemic has had a ripple effect, impacting not only those people who have contracted the virus, but the tens of millions of others who have managed to avoid it.  Many have foregone recommended preventive and well care since March 2020. Studies confirm this trend, including a recent report from Avalere on routine vaccinations missed.  From January 2020 – July 2021, monthly vaccine claims (for routine vaccinations excluding COVID) decreased an average of 32 percent for adults and 36 percent for adolescents, compared to the same months in 2019.  A poll conducted in January 2022 found that 30 percent of adults aged 50 and older missed a scheduled appointment for a medical test, procedure or operation.

Israel Cordero, M.D., medical director of primary care for Middlesex Health in Connecticut, attested to this troubling trend during a recent interview with WFSB TV. “We have seen many patients delay routine and preventive care, as well as ongoing chronic disease management,” said Dr. Cordero, a long-time Vatica client. “We are seeing some of those aftereffects of delaying care during the pandemic.”

While all age groups are affected, seniors are among those most at risk from delayed or avoided care. Whether it’s a colorectal cancer screening, a flu vaccine or an eye exam for a person with diabetes, missing a recommended test or procedure could have significant long-term effects. To help keep seniors healthy and reduce the enormous amount of money spent on treating preventable illnesses, Medicare covers a number of preventive services. For example, the Annual Wellness Visit (AWV), which is informed by a comprehensive health risk assessment, focuses on early detection, positive lifestyle choices, and utilization of preventive services.

Only one in four beneficiaries receives an AWV, despite this service being 100 percent free. Unfortunately, many other preventive services are also underutilized. This problem has been exacerbated by COVID, demonstrated by the studies cited here. As we start to return to our pre-COVID lives, we must ensure that the most vulnerable among us–including seniors–get the routine and preventive care they need. This requires communication, creativity and collaboration.

Partnerships between payers and providers are one way to tackle this problem. Payers and providers are using a variety of outreach and incentive programs to get patients in the door, from multi-model outbound messaging and mailers to gift cards and greeting cards.  Another effective approach is leveraging health plan initiatives that provide physicians with clinical and administrative support as well easy-to-use technology.  Finally, marrying preventive services with payer-sponsored programs designed to capture and close risk and quality gaps benefits the entire healthcare ecosystem: plans, providers, and patients.

Given their vulnerabilities and higher prevalence of chronic conditions, older Americans were prioritized when the COVID vaccine was initially rolled out. Likewise, a similar focus is needed to reengage seniors in preventive and routine care. As the nation emerges from the acute phase of COVID, it’s critical to refocus on mitigating the development and exacerbation of chronic and preventable diseases. There are effective steps providers and payers can take together to ensure that seniors—some of our most vulnerable population—catch-up on preventive care and reduce their likelihood of developing serious illnesses.

How Vatica Health can help

Vatica Health is a pioneer in physician-centric technology that supports improvements in clinical outcomes, efficiency, and financial performance. The Vatica solution deploys clinical nurses at the point of care, armed with powerful technology. The nurses use Vatica’s solution to identify, document, and report gaps in care, helping physicians increase the utilization of preventive services such as colonoscopies, mammograms and diabetes screenings. Vatica Health is accelerating the transformation to value-based care by helping providers, health plans, and patients work together to achieve better outcomes. To learn more, visit https://vaticahealth.com/.

Why a “Technology-Only” Approach Will Not Drive Value-Based Care Performance

By Vatica Health | February 16, 2022 | Provider, Risk Adjustment, Value-Based Care

Over the last few years, we’ve witnessed significant advancements in medical technology including the proliferation of telehealth, remote patient monitoring, and artificial intelligence. These offer the potential to dramatically improve insights and shape healthcare delivery. While technology development is essential, it must properly interface with clinical services to drive the maximum benefit—for providers and for patients.

Recent technology developments that provide coding and care gap notifications in electronic medical records (EMRs) offer increased potential for value-based care. These solutions address an important problem—but are incomplete as they don’t ensure conditions are coded correctly. Patients must have their conditions accurately coded to ensure health plans and providers receive appropriate compensation. Accurate coding can lead to cost-effective clinical services with the goal of improving patient outcomes.

In reality, these “technology-only” solutions may compound the problem. Providers are inundated with competing priorities and lack resources to add additional uncompensated services—a situation exacerbated by COVID-19. Current solutions cause alert fatigue and have little impact on care. They also suggest insights based on unsubstantiated data and therefore create compliance risk.

Value-based care requires a comprehensive solution

The transition to value-based care is inevitable. By 2025, it is anticipated that all Medicare Advantage and traditional Medicare plans will adopt two-sided risk alternative payment models. Fifty percent of Medicaid and commercial plans will adopt these models. This move requires providers to accurately code services for appropriate risk-adjusted reimbursement, connecting financial performance and quality of care. Success in value-based care depends on accurately assessing patient needs so that provider payments—based on the reported health conditions for that patient—will be sufficient to deliver appropriate care.

Technology cannot replace providers and clinical judgement. To drive optimal performance in value-based care, consider leveraging powerful, clinically validated technology coupled with clinical experts. By using technology combined with clinical experts, care gaps and relevant diagnostic codes can be identified. Such comprehensive services lead to more accurate coding and better performance in value-based care for both providers and health plans.

Evaluating possible solutions

There are a growing number of solutions that promise to drive value-based care performance, but very few that provide a comprehensive approach to improving risk adjustment coding and quality of care. Here are three questions to consider when evaluating various solutions:

  1. Is the risk adjustment and quality solution provider-centric? Providers need intuitive, easy-to-learn, and simple-to-use technology that seamlessly fits into their workflow, uses their EMR and intelligently mines data to optimize efficiency.
  2. Does the solution provide comprehensive in-office support? In addition to data and technology, providers need access to onsite clinicians who understand the technology and serve as an extension of their team at no cost to the practice. These clinicians can perform various tasks to reduce the burden on providers and their staff.
  3. Does the solution ensure coding accuracy and compliance? While there are “technology-only” solutions that surface codes in providers’ EMRs, they are often derived from unreliable data sources and not validated by certified clinical coders. This creates audit and compliance risk.  

How Vatica Health can help

Vatica Health is a pioneer in provider-centric technology and support solutions that directly improve clinical outcomes, efficiency, and financial performance. Vatica Health deploys clinical nurses at the point of care, armed with powerful technology. Vatica Health is accelerating the transformation to value-based care by helping providers, health plans, and patients work together to achieve better outcomes. Visit https://vaticahealth.com/ to learn more.

6 Ways to Ease Physicians’ Burden From Coding, Documentation and Risk Adjustment

By Vatica Health | February 3, 2022 | Provider, Risk Adjustment, Value-Based Care

By Shannon Lukez, Senior Vice President, Clinical Solutions, Vatica Health | This article first appeared on HFMA

The COVID-19 pandemic has heightened the need for the nation’s hospitals and health systems to gain physician cooperation in documenting and coding patient risk.

The reason is that many patients, and particularly the elderly, stopped visiting their care providers during the pandemic, often resulting in an undocumented deterioration of their health status.

Consider, for example, a 76-year-old patient with Type 2 diabetes and stage 3 chronic kidney disease, whose conditions were fully documented in the patient’s medical record and coded to the highest degree of specificity on all claims submitted in 2019. Let’s assume the patient not only refrained from visiting a physician’s office in 2020 due to COVID-19, but also was not comfortable enough with technology to receive telehealth services. Facing isolation, with severely reduced family and community support, the patient experienced growing depression and anxiety — and uncontrolled diabetes. The patient also began experiencing symptoms of high blood pressure and severely reduced access to healthy food as result of the increased financial strain brought on by the pandemic. Because the patient did not see a physician in 2020, none of this information was documented in their medical record or coded.

Undocumented deterioration in a patient’s health status impacts a healthcare organization’s revenue considerably. The absence of preventive care significantly increases the possibility for patient illness and premature death, while also depriving healthcare providers the opportunity to positively impact the patient’s life. Failure to recapture previously documented conditions, as well as new ones, leads to poor patient outcomes and lower levels of reimbursement.

The added challenge of physician burnout

Unfortunately, this heightened need for physician engagement comes at a time when many physicians are struggling with burnout exacerbated by the challenging work conditions created by the pandemic amid the ever-present risk of contracting the virus.

According to a 2021 national survey conducted by Medscape, 42% of physicians reported feeling burned out. Interestingly, 79% said the burnout started before the pandemic, with a majority (58%) citing “too many bureaucratic tasks” as the number-one cause.

These circumstances may cause many healthcare finance leaders to feel hesitant to add to physicians’ plates any kind of operational burden, particularly tasks related to enhanced coding, documentation and risk adjustment. It’s not easy to ask physicians — especially those who are salaried — to spend more time documenting conditions and reporting data for value-based payment programs while also increasing daily patient volume. Yet the financial future of a healthcare organization depends on its ability to delicately balance and accurately perform both tasks. As the industry shifts from volume-based to value-based payment models, healthcare organizations and physicians must cooperate to achieve long-term financial viability.

Consequences of physician burnout

Physician burnout is problematic because it leads to unsatisfied physicians and high turnover, which significantly affects patients. For example, burnout is associated with higher rates of major medical errors. It can also negatively affect patients’ access to and continuity of care as well as their care experience. All of these issues can harm a healthcare organization’s reputation and, in turn, its bottom line. For these reasons, physician burnout is an important ongoing concern for healthcare finance leaders.

How to foster physician engagement in capturing risk

Addressing these challenges requires a strategic approach to making coding and risk adjustment practices more physician friendly. Following are six strategies that CFOs should consider as they strive to support physicians in more accurately and documenting the risk profile of their patients.

1 Provide physicians with training on standard coding and documenting practices. One of the challenges associated with creating a risk-adjustment strategy is getting all physicians on the same page in terms of process and workflows. All too often, each practice — particularly one that’s newly acquired — will either have its own way of capturing risk or have no formal process at all. Consistency is important because it reduces the cost to operationalize the program, permits standardization of training and other key elements, and facilitates the establishment of expectations. Both the healthcare organization and the physicians will know exactly what is expected.

2 Align physician compensation with value-based care initiatives. Compensating physicians for their efforts is of paramount importance to obtaining physician buy-in and ongoing participation. Yet some healthcare executives contend that coding and documentation are simply part of the physicians’ role, so extra compensation is unnecessary.

This perspective does not consider newer models of care that focus on population health and outcomes, where revenue is largely determined by value, affordability and outcomes. And outcomes and value will be determined through analyses of claims and encounter data, which must be supported by accurate and thorough medical records documentation.

Aligning physician performance and compensation with overall organizational goals ensures shared accountability. Just as important, by thoughtfully designing compensation programs for both clinical and support staff, a health system can proactively counter the problems of physician burnout, declining retention and a growing shortage of talented physicians.

Paying physicians a base salary plus a gain-share bonus based on value-based care performance, for example, gives them an incentive to go the extra mile documenting for risk adjustment. It also sends the message to physicians that executive leaders are aware of the extra time and effort improved coding and documentation requires.

3 Optimize the electronic health record (EHR). EHRs, on their own, do not sufficiently support coding and documentation to optimize value-based care performance. However, solutions are available that optimize EHR performance to help identify care gaps and facilitate accurate coding.

Physicians need help with this process as risk adjustment coding is complex and cumbersome. In the CMS risk adjustment model alone, roughly 10,000 diagnoses are assembled into about 1,300 diagnostic groups that are then aggreged into condition categories (CCs). CCs are related clinically and with respect to cost. Hierarchies are imposed among related CCs, hence the term hierarchical condition categories or HCCs. HCCs paint a complete picture of each beneficiary’s acuity to effectively manage costs for high-risk members while ensuring they receive high-quality care and the organization receives appropriate and accurate payment.

Efficiently distilling this information for physicians reduces the burden on them and improves performance in value-based care, quality and risk adjustment initiatives. Healthcare organizations should work with their EHR vendors on ways to improve EHR performance to optimize the provider experience and patient outcomes.

4 Advocate for programs that remove operational burden associated with risk adjustment. For example, health systems could consider working with a health plan on a plan-sponsored program for primary care physicians (PCPs) that is easy to use and provides support to physicians. Such programs can combine powerful technology with clinical and administrative resources dedicated to medical practices.

These programs can help the participating health systems realize incremental revenue, improved outcomes, increased numbers of preventive health encounters (e.g., annual wellness visits) and improved overall performance in value-based care arrangements. The senior financial executive can initiate this strategy by reaching out to the organization’s managed care partners to see whether they provide this type of program and, if so, what type of performance reporting is included. Ideally, the health plan would provide real-time data so the physicians could understand care gaps for each patient and how well they are addressing those gaps.

If health plans don’t offer this option, the health system could consider developing a program internally, depend on its goals, available resources and competing priorities. In deciding whether to pursue such an approach without outside help, the organization would need to perform an in-depth assessment of the potential benefits weighed against the costs associated with the required  upfront investment and ongoing resources for program management, analytics and reporting.

Armed with the results of such an analysis, the senior finance executive can champion the effort by communicating to the health system’s C-suite the potential financial impact of a PCP-focused program to the health system, and how it could help the organization not only survive, but thrive, in the years ahead. In this way, the senior finance leader also can help demonstrate to the physicians that there is uniform buy-in at the leadership level for a program designed to help them manage the risk-adjustment process.

5 Provide support to help physicians capture and address social determinants of health. Medical care accounts for only 10% to 20% of the modifiable contributors to healthy outcomes. The other 80% to 90% are referred to as social determinants of health (SDoH) — the conditions in the environments where people grow, live, work and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Examples of SDoH include the lack of essential resources necessary to maintaining health, including housing and economic stability, literacy skills and access to nutritious food and physical activity opportunities. Because SDoH often can affect risk adjustment and, consequently, revenue, it is important for physicians to capture this information.

Healthcare organizations should assist physicians in this effort by providing a framework and support for capturing SDoH. Successful SDoH-focused programs include training clinical staff, providing access to local resources, developing workflows and promoting standard practices that help simplify the risk-adjustment process, including allocating time during patient encounters for these critical conversations.

6 Be transparent about the financial impact of physician performance in value-based care. Given the significant impact physicians have on a health system’s performance under value-based payment arrangements, executive leaders should share financial performance data with physicians (and potentially other staff as well). For some healthcare organizations, incremental revenue earned through participation in such programs can help them end the year in a financially positive position. Transparently communicating to physicians the financial impact of performance in value-based-payment contracts, including positive results attributed to quality and risk adjustment programs, builds awareness, trust and engagement.

A necessary charge

Value-based care is a strategic imperative for U.S. hospitals health systems, and it requires, first and foremost, physician engagement. Thus, although finance executives may be wary of asking physicians to take on the additional administrative tasks such contracts require, they must do so because success will depend on physicians’ absolute commitment to accurately documenting care and adjusting for risk. Although physicians may initially object to the additional work, they will likely become more receptive if they can be shown how better coding and documentation directly improves the organization’s financial performance — and how that translates into reduced pressures placed on physicians.

It is here where the finance leader can make a difference. By examining and implementing  creative and effective solutions aimed at easing the administrative burden on physicians, the senior finance executive can help them better meet the challenge of performing documentation and coding. The result is a win-win in the form of improved value-based payments and alleviated physician burnout.

Why providers face an increased challenge in understanding patient risk

During the first six months of 2020, an estimated four out of 10 adults in the United States avoided medical care because of concerns related to COVD-19. With these delays in care came missed opportunities for hospitals and health systems to capture risk and predict costs accurately.

With the rollout of the COVID-19 vaccine, some patients are slowly resuming preventive services, which is good news. Yet this trend means providers may be overwhelmed with patients whose chronic conditions have worsened or who are newly diagnosed with a chronic condition. It is of paramount importance that the provider organizations capture these diagnoses to ensure their payment is appropriately adjusted for risk.

For patients who are still not returning to their provider, it also will be important for providers to address care gaps. Telehealth may be a great way to engage these patients so that physicians can capture risk without necessitating the need for an in-person visit.

In addition, in 2020, about 8.3 million people signed up for Affordable Care Act plans that rely on risk-adjusted payment models. This is a new population of patients for whom risk adjustment suddenly matters. Many of these patients don’t have a baseline risk adjustment factor score, making it critical to capture any and all diagnoses that affect risk-adjusted payments as soon as possible.

A Solution for Medicare Advantage Overpayments: Taking a Provider-Centric Approach—Not Suspect Analytics

By Averel Snyder, MD | January 19, 2022 | Risk Adjustment, Value-Based Care

By Averel B. Snyder MD, CMO, CRC, CPC, CDEO, Vatica Co-Founder and Chief Medical Officer

Driven by a flurry of lawsuits and Office of Inspector General (OIG) reports alleging billions in overpayments, government pressure is mounting for Medicare Advantage Organizations (MAOs) to improve risk adjustment practices. Before we delve into how MAOs can effectively address the increased compliance scrutiny, it’s instructive to consider how we got here.

The Evolution of Risk Adjustment

The beginnings of Medicare Advantage (also known as Medicare Part C) go back to the 1970s. At that time, beneficiaries could receive managed care through private insurance companies. It was not until 1997 that the program, then called “Medicare Choice,” became official with the passing of the Balanced Budget Act. In 2003, Medicare Part D was created, and Medicare Choice plans were renamed “Medicare Advantage” plans. A major change in the program addressed favorable selection in Medicare Advantage and was phased in from 2004 to 2007. This introduced a new system for adjusting plan payments based to a large extent on severity of illness for each beneficiary. The system requires the health plans to submit to CMS the diagnosis data annually as each member is assumed to have no diagnostic conditions at the start of a new calendar year.

The new system created an industrywide frenzy to capture all diagnoses to optimize risk adjusted revenue.   This spurred new business models to help MAOs document members’ active medical conditions. These businesses include companies providing home health assessments, suspect analytics, gap closure programs, natural language processing, and machine learning to name a few. Many of these businesses focused more on increasing revenue at all costs without an equal, or greater, focus on improving the accuracy and completeness of coding and documentation.  Likewise, some health plans have developed internal coding programs that lack adequate safeguards to ensure the accuracy of conditions submitted to CMS.

The Challenge Around RADV Audits

As the government increases RADV audits, warning signs indicate that industry practices may need an overhaul. For example, a recent RADV audit of Plan A revealed that only 40% of 203 sampled enrollee-years had medical records supporting the diagnosis codes submitted to CMS. For the remaining 123 enrollee-years, the diagnosis codes were not supported in the medical records.  A RADV audit of Plan B found 43% of beneficiary risk scores invalid due to not supporting one or more diagnoses for the following reasons: the documentation did not support the associated diagnosis, or the diagnosis was unconfirmed. Similar reasons were responsible for the results of Plan C’s audit with only 54% of risk scores being valid.

The Problem with Retrospective Chart Reviews

The OIG released findings in a report dated December 2019 relating to supplemental diagnosis codes that were not linked to an encounter. This practice is used when submitting retrospective codes via a CMS submission in either Risk-Adjusted Processing System (RAPS) or an unlinked chart review through Encounter Data Processing System (EDPS). Of the submissions, it was found that $1.7 billion of the total $6.7 billion risk-adjusted payments were retrospective chart reviews. The OIG also found that within all chart review submissions, only 1% accounted for deletions for previous erroneous codes submitted. Regarding the supplemental unlinked chart reviews submitted, half were linked to only 10 hierarchical condition categories.

What I Learned Firsthand

I was a practicing clinical physician for 30 years before my 10-year involvement with Medicare Advantage. For 30 years, I would review the patient’s medical record prior to a face-to-face visit so that I could address those active medical conditions during the visit. I may have been more efficient, had a trained nurse or mid-level reviewed the record and presented me with all the active medical conditions, along with the documentation and clinical validation found within the medical record.

I strongly believe that had I been presented ‘lists’ composed of ‘suspect conditions’ or ‘other’ provider claims history, or lists generated by natural language processing, and machine learning, the abundance of false positive diagnoses generated by these techniques would have made me much more prone to err in documenting and coding inaccurate and non-compliant active medical conditions. On the other hand, a physician or mid-level provider responsible for patient care with access to mined data from that patient’s medical record prior to a face-to-face visit is the ideal process for Medicare risk adjustment.

What Comes Next

Due to a confluence of factors, including increased lawsuits, OIG reports claiming billions in overpayments, and negative RADV audit results. A strategy based on claims data and suspect analytics increases negative RADV exposure similar to the 40% to 50% unsupported conditions in recent RADV audits. MAOs should consider a physician-centric approach to risk adjustment, which should provide physicians with technology and expertly trained mid-level or nurse support. As a result, this will drive more accurate and complete coding and documentation to improve overall compliance and results.  

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Dr. Averel Snyder is a cardiothoracic surgeon and is board certified in general surgery, critical care medicine and cardiothoracic surgery. He practiced heart surgery for over 25 years. He also has an AMA certification in age management, and several medical coding certifications (CRC, CDEO and CPC). Dr. Snyder is co-founder of Vatica Health, the leading PCP-Centric solution for risk adjustment and quality of care. To learn more about Vatica Health, please visit vaticahealth.com