Category: Risk Adjustment

CMS-HCC and risk adjustment: everything you need to know

By Vatica Health | December 19, 2024 | Risk Adjustment

Every patient has a story. The question is, are you—as the provider—telling the most important aspects of it, or are you missing critical details? We’re talking about the details that affect the patient’s health status and predict the resources required to care for them—two pieces of information that play a critical role in risk-adjusted payment models.

This article covers some common questions and topics surrounding risk adjustment and HCC coding. It is designed to help providers navigate a changing landscape.

What is risk adjustment in Medicare Advantage?

Risk adjustment promotes fairness and patient access in the Medicare Advantage (MA) program by ensuring that payments to health insurance plans or providers reflect the health status and needs of the individuals they serve. By accurately accounting for the health status of patients, risk adjustment ensures the appropriate funding is available so health plans can cover the cost to address patients’ full burden of illness. Without it, plans might be incentivized to avoid enrolling patients with complex medical needs to reduce costs.

How risk adjustment is calculated in Medicare Advantage

Graphic describes the three-step process involved in risk adjustment. 1. Beneficiaries receive their Medicare benefits via private health plans. 2. The Centers for Medicare & Medicaid Services (CMS) pays these health plans based on the health status of each member. 3. Health status is based on demographic and disease factors. Disease factors are based on the provider coding.

Provider documentation and risk adjustment

The provider—through their documentation—tells the patient’s story using the “language” of ICD-10-CM diagnosis codes. When combined with demographic data and other details, the patient’s health status becomes clearer.

Diagnostic coding plays a critical role in risk adjustment by providing more accurate and comprehensive information about the health status of individuals. If diagnostic coding is inaccurate, it can have significant impacts on providers and their patients:

  • Financial implications: Under/overpayments or under/overbilling
  • Compliance issues: Legal liabilities, fines and reputational damage
  • Compromised care: Incorrect treatment decisions, delays or unnecessary procedures
  • Healthcare system inefficiencies: Claim denials and payment delays

What does CMS-HCC stand for, and how does it work?

CMS-HCC stands for Centers for Medicare & Medicaid Services-Hierarchical Condition Categories. It is a risk adjustment model used by CMS to adjust payments to MA plans.

Specific ICD-10-CM codes map to specific HCC categories—although not all ICD-10-CM codes map to an HCC category and thus don’t affect risk adjustment. While codes that represent chronic or serious conditions with a significant impact on healthcare costs are represented, the CMS model excludes diagnoses that are vague/nonspecific (e.g., symptoms), discretionary in medical treatment or coding (e.g., osteoarthritis), not medically significant (e.g., muscle strain), or transitory/definitively treated (e.g., appendicitis).

In the CMS model, those conditions that do affect risk adjustment, which are roughly 10,000 out of 70,000+ diagnoses, are grouped into approximately 1,300 diagnostic groups (DXG) that are then aggregated into condition categories (CC). CCs are related clinically and with respect to cost. Hierarchies are imposed among related condition categories. This means that a patient is coded for only the most severe manifestation among related diseases. Hence the term “hierarchical condition categories,” or HCC. HCCs accumulate among unrelated diseases, and the model accounts for interactions between certain conditions for which costs can be exacerbated (e.g., diabetes and congestive heart failure).

The CMS-HCC model uses these mappings to calculate a risk score for each patient, which reflects the expected healthcare costs. This score helps determine the amount of funding provided each month to Medicare Advantage plans. HCCs paint a complete picture of each beneficiary’s acuity to ensure appropriate and accurate funding, effectively managing costs for high-risk members and delivering high-quality care.

Impact of accurate documentation and code capture

Check out the example below that illustrates an $18,500+ difference in payment under the CMS-HCC model based on whether the provider captures accurate diagnoses with maximum specificity.

Graphic illustrates an $18,500+ difference in annual payment under the CMS-HCC model based on whether the provider captures accurate diagnoses with maximum specificity.

Figure 1. Payment by CMS-HCC based on coding specificity

Understand how the CMS-HCC Version 28 Model evolved

A new version of the CMS-HCC model was finalized in 2023 for implementation beginning in calendar year 2024. The new version, V28, replaces the most recent V24. As CMS explains, the existing HCCs that were used in the 2020/V24 model were built using ICD-9 codes, which they had to map to the newer ICD-10-CM codes while waiting for coding practices to stabilize.

For 2024, CMS undertook a CMS-HCC reclassification that involved building new condition categories from the ground up leveraging the increased specificity of ICD-10 coding, reviewing each diagnosis and determining the best grouping of diagnoses. Updating the underlying data and the clinical reclassification is meant to improve predictive ability by better reflecting current disease patterns, treatment methods and costs, and diagnosis and coding practices, says CMS. Some of the noteworthy changes include an expanded number of payment HCCs (115 from 86), changes in ICD-10-CM to HCC mapping (20% fewer codes) and adjustments in coefficient values.

V28 has been phased in over a three-year period. Per CMS: “For CY 2024, risk scores will be calculated as a blend of 67% of the risk scores calculated with the current model (the 2020 model) and 33% of the risk scores calculated with the updated model (the 2024 model). For CY 2025, we expect risk scores to be calculated as a blend of 33% of the risk scores calculated with the 2020 model and 67% of the risk scores calculated with the 2024 model, and for CY 2026, we expect 100% of the risk scores to be calculated with the 2024 model.”

The importance of accurate coding in CMS-HCC V28

Thorough and accurate documentation and coding is always important, but V28 will require even greater specificity in documentation and code assignment. Providers must adapt to the changes to ensure the health and stability of their patients and their practice.

  • Proper risk adjustment: Accurate coding ensures at-risk entities receive appropriate funding to cover the care needs of their enrollees so they can deliver quality care to patients with complex health conditions.
  • Financial performance: For healthcare providers and MA plans, precise coding influences reimbursement rates, maintaining financial stability and supporting the sustainability of healthcare services.
  • Full health picture: Accurate HCC coding reflects the true health status of patients and enables the identification of patients who may benefit from targeted interventions like screenings or medications, ultimately leading to improved patient outcomes.
  • Compliance: Inaccurate coding can lead to compliance issues, including audits and penalties, undermining a practice’s reputation and impacting its bottom line.
  • Data health integrity: Reliable data is essential for public health analysis, research and policy-making. It aids in identifying trends, managing population health and making informed decisions.
  • Benchmarking: Accurate data allows organizations to evaluate their performance accurately, identify areas for improvement and implement strategies to enhance care quality.

CMS-HCC coding best practices

Adhering to best practices ensures compliance, proper risk adjustment and, ultimately, better patient care. Here are some key practices to follow for effective HCC coding.

  1. Perform a valid face-to-face encounter. Note that telehealth visits are considered equivalent to face-to-face interactions and are subject to the same requirements regarding provider type and diagnostic value.
  2. Use the “DSP” acronym as a best practice guide for documentation:
    • D: Diagnosis – Refers to the patient’s active medical condition or health issue that is being treated or monitored.
    • S: Status – Includes the current signs, symptoms and how the disease or condition is progressing (or regressing).
    • P: Plan – Outlines the course of action or treatment plan, which may include medications, procedures, follow-up appointments or lifestyle changes to address the patient’s condition.
  1. Link diagnoses with manifestations using a linking statement or other document.
  2. Add all diagnosed conditions to both the chronic problem list and assessment.
  3. Submit all relevant ICD-10-CM diagnosis codes, including Z codes.
  4. Ensure the medical record includes a legible signature with name, date and credentials
  5. Ensure the diagnoses being billed match the actual medical record documentation.
  6. Always remember the golden rule of medical record documentation.

Optimizing coding with a risk adjustment solution

One way to minimize risk and to increase revenue is to participate in a health plan-sponsored risk adjustment program that helps providers tell the patient’s story as accurately and completely as possible—all while minimizing the impact on staff and internal processes.

Benefits of payer-sponsored risk adjustment and quality programs 

By Vatica Health | August 14, 2024 | Provider, Risk Adjustment, Value-Based Care

As provider groups struggle with increasing demands and staffing challenges, two physician leaders presented solutions to both. During a webinar sponsored by the RISE Association, Richard Charles, MD, chief medical officer of General Physician, PC, and Jagraj Rai, MD, president of Guthrie Lourdes Medical Group, spoke about payer-sponsored programs that have helped both their patients and their practice.  

You can watch the webinar here or read on for highlights. 

Dr. Charles noted that he and his colleagues had criteria for an in-office program to support risk adjustment and quality requests from payers. It had to be quick and easy for physicians and integrate with their current workflow. It needed to help the physician before and after the visit, with incentives for the treating PCP. 

According to Dr. Charles, a payer-sponsored solution from Vatica helped his group identify the true burden of illness for their patients to accurately stratify them and deliver appropriate care. Vatica’s pre-visit notification identified gaps in care to help the practice improve HEDIS scores as shown in the graph. General Physician also increased risk score accuracy by about 10% per patient. 

Vatica gap closure rate
Compared to 4-star rating; claims paid through 1/31/23

More accurate coding and documentation, along with the incentive offered by the payer, allowed the practice to add support services such as care management and enhanced pharmacy programs. Both are valuable resources to help PCPs address conditions and close care gaps, resulting in increased patient satisfaction, improved outcomes and additional practice revenue.  

Dr. Charles shared tips for the webinar’s payer audience. He recommended sharing data with PCPs so they can understand how coding and documentation affects the practice’s financial performance. Provide a payer-agnostic solution that’s easy and efficient. General Physician’s average time to complete a review is only 2 minutes/patient.  

Dr. Rai’s practice has similar requirements for a risk adjustment program. He stressed the importance of sharing incentives with treating PCPs. While it took six months of work with several departments in the practice, he found that passing along the incentive to PCPs has a major impact. In the first five months of 2024, the practice has more than doubled the number of completed visits during the same period in 2023. 

Dr. Rai lauded the pre-visit summary that lists conditions to address, open care caps and prescriptions to reconcile. The ideal time to address those issues is when the PCP is face to face with the patient. The summary saves the PCP significant time, requiring less chart review. 

“I continue to marvel about our team at Vatica because they are there at every step,” he adds. “They provide education. Sometimes our clinicians may forget to complete the chart. The Vatica team reminds them. We may need a little more education, and they’re always there.”  

Moderator Whitney Chernoff, senior VP of client engagement at Vatica Health, summarized the key takeaways. She noted that tech-only solutions often create more work for the PCP. Having trained clinicians in the process helps ensure that PCPs are looking at the most accurate data. All three speakers highlighted the importance of sharing incentives with treating providers and hiring needed staff with the funds. In the end, addressing chronic conditions and closing care gaps makes patients healthier and supports lower overall healthcare spend, which is everyone’s goal.

Maximizing quality of care. Minimizing admin load.

By Vatica Health | July 12, 2024 | Risk Adjustment

Effective risk adjustment drives value-based care performance and promotes fairness and equity in the Medicare Advantage (MA) program by ensuring that payments to health insurance plans and providers reflect the health status and needs of the patients. 

The keyword here is effective. For risk adjustment to deliver on its purpose and its promise, all parties involved—patients, providers and payers—must be coordinated and aligned. The trouble is, legacy programs, such as Health Risk Assessments (HRAs) completed by in-home assessment vendors, remain disconnected from treating providers. While HRAs can be a helpful tool in identifying active conditions, diagnoses captured in HRAs are often not recorded in a subsequent medical visit. Detached programs and practices can undermine the purpose of risk adjustment, increase the risk of non-compliance with evolving regulatory requirements and fail to adequately support and incentivize providers in their transition to value-based care (VBC).

The modern healthcare ecosystem is increasingly complex. Risk adjustment programs that exclude the Primary Care Physician (PCP) are inefficient, create provider-patient friction and amplify risk. Physicians and their teams need a risk adjustment solution that makes coding and documentation easier and leads to high-quality outcomes for their practice and their patients.

Here’s how Vatica Health’s one-of-a-kind risk adjustment and quality of care solution can complement current coding and documentation processes and enhance risk adjustment without overextending staff or sacrificing precious time and resources. 

1. Prioritizes coding accuracy and completeness


Why it matters

Accurate coding is the backbone of effective risk adjustment, ensuring risk scores are calculated correctly and reflect the true health status of enrollees. HRAs, typically performed in-home by vendors on behalf of MA plans, can lead to inflated HCC scores and compromised care.


How Vatica delivers

  • Point-of-care integration: Vatica works at the point of care and proactively surfaces the most appropriate and up-to-date conditions for PCPs to validate. Physicians can focus on their patient interaction, knowing they have a complete and accurate picture of the patient’s conditions.
  • Holistic data collection: Unlike other solutions, Vatica collects and analyzes data from various sources, as well as unstructured data, including consult notes and medical images, offering a more comprehensive picture of a patient’s health. No need for PCPs to connect the dots between various systems and sources.
  • Clinical review: With Vatica, 100% of patient encounters are reviewed by clinicians, such as RNs with advanced coding certifications. This ensures accuracy, completeness and compliance—and offers peace of mind for PCPs.


2. Works with and for providers


Why it matters

Any risk adjustment solution that providers adopt needs to reduce friction, not add to the already taxing administrative load. A flexible and user-friendly solution that meets PCPs where they are ensures effective and robust use, promoting better outcomes for everyone.


How Vatica delivers

  • Provider-centric approach: Comprehensive pre-encounter work performed by Vatica clinicians arms providers with the most clinically relevant information to deliver the highest quality of care during patient visits. Providers remain at the center of care to diagnose, document and follow up.
  • Workflow compatibility: Vatica’s EMR-independent technology works within existing workflows, meeting providers where, how and when they work. 
  • Administrative support: The unique Vatica model includes expert clinician coding support, allowing PCPs more time to deliver high-quality care and assuring that coding and documentation will be accurate, complete and compliant.
  • Payer-agnostic: Vatica is payer-agnostic. Clients include most national health plans and many regional plans. 


3. Supports better outcomes for patients and PCPs


Why it matters

Accurate risk adjustment is a cornerstone of value-based care. Continuing to rely on legacy programs like HRAs and chart reviews that might not reflect the true status of health—and can lead to inflated HCC scores and inaccurate risk-adjusted payments—flies in the face of VBC principles and sets providers back in their journey.


How Vatica delivers

  • Help in identifying care gaps: Vatica flags open HCC coding and care gaps for PCPs to address during encounters. Real-time clinical data assists providers in addressing HEDIS measures during their interaction.
  • Accurate VBC benchmarking: Vatica empowers providers to make the PCP visit the foundation for VBC benchmark accuracy. PCPs can deliver continuous, more effective care and build stronger patient relationships. 
  • Revenue opportunities: Vatica helps PCPs earn additional revenue through reimbursable visits, health plan incentives and enhanced VBC performance.


Better risk adjustment benefits everyone

Vatica Health’s Best in KLAS® risk adjustment solution is designed to help health plans, providers and patients achieve better outcomes, together. By increasing patient engagement and wellness, improving coding accuracy and compliance, and helping identify and close gaps in care, Vatica helps ensure that everyone benefits.

What’s behind the move from retrospective to prospective risk adjustment?

By Vatica Health | July 10, 2024 | Provider, Risk Adjustment

Health plans across the country are recognizing the superior value of prospective risk adjustment programs, and rightfully so. These programs have impact at the point of care, as opposed to retrospective programs which are essentially chart reviews. Prospective risk adjustment programs permit timely, effective interventions. This includes presentation of suspected gaps in care and the opportunity to achieve thorough and accurate documentation, which supports coding to the highest degree of specificity.

Conversely, backward-looking retrospective risk adjustment programs limit effectiveness of code capture. A risk adjustment program consisting only of retrospective chart reviews is myopic and does not support the outcomes-driven, population health management focus inherent in most payment models today.

Which one is the optimal approach to risk adjustment? The answer: an effective mix of both. But most important is primary care physician (PCP) engagement. A winning risk adjustment strategy is heavily weighted towards prospective interventions but may need to include some retrospective elements to meet PCPs’ needs.

Prospective programs, while more operationally complex to deliver, are preferred because the ability to impact behavior at the point of care is powerful. It has significant cascading effects, including higher overall value, return on investment and reduced compliance risk. When coupled with PCP engagement, prospective risk adjustment can be the most effective method for obtaining comprehensive insight into the disease burden of a population. Prospective risk adjustment also enables forecasting the cost of care for your Medicare Advantage, Medicaid and commercial lines of business.

PCP engagement is the key to success across all risk adjustment strategies, especially prospective programs. PCP engagement improves care delivery and closes gaps in care by leveraging a proactive approach providing timely clinical and administrative support, education and performance management.

The challenge: Finding a prospective risk adjustment program that engages PCPs

Ideally, health plans and physicians would collaborate to reduce costs and improve health, quality and outcomes. Additionally, members would self-advocate and proactively schedule preventive and wellness visits. Unfortunately, true engagement among all stakeholders in the healthcare continuum is rare and difficult to attain. Physician engagement requires timely, ongoing support. It is essential to augment practices with dedicated clinical resources who curate information to save the physician time by streamlining coding and surfacing gaps in care that require consideration during the encounter.

Furthermore, support staff who provide insights on performance and drive physician engagement are critical. Successful programs supply expertly trained people, easy-to-use technology, turnkey processes and aligned financial incentives to achieve and maintain physician engagement.

Lastly, member engagement is an important piece of the puzzle. Physicians are more likely to engage in programs that drive material clinical improvements for their patients, such as improved outcomes and quality of life.

How Vatica Health can help: Aligning stakeholders around a common goal

Vatica Health is a compliance-first organization that enables a physician-centric approach to risk adjustment and clinical quality. We pair expert clinical teams with cutting-edge technology to work with physicians at the point of care. Vatica Health synthesizes EMR and health plan data to create the most comprehensive and complete view of each patient. We provide comprehensive PCP training as well as 100% clinical coding validation. All unsubstantiated codes are deleted prior to submission of the Vatica record to the health plan sponsor.

Advantages of partnering with Vatica Health

Our licensed registered nurses and administrative staff are dedicated to providing the best experience for PCPs and their office staff. Our attention to documentation and coding validation through Vatica’s quality improvement process improves accuracy and reduces compliance risk. Vatica’s clinical and administrative staff work closely with each practice to develop a custom workflow and process, achieving an ideal state that yields the best results with the least amount of effort for PCPs.

When health plans partner with Vatica Health, they ensure a comprehensive, collaborative and prospective risk adjustment program that’s a win-win for everyone, including patients. To learn more, visit vaticahealth.com.

Another blow to detached health risk assessments

By Vatica Health | June 4, 2024 | Provider, Risk Adjustment, Value-Based Care

By Brian Flower, vice president of client solutions, Vatica Health

Health Affairs recently published a study of data from 4 million Medicare Advantage (MA) members indicating that health risk assessments (HRAs) contributed up to $12 billion per year to risk adjusted payments in 2020. This is based on conditions that were submitted exclusively by an HRA (not submitted through another encounter) during the 2019 calendar year. The study implies that HRAs, typically performed in-home by vendors on behalf of MA plans, can lead to inflated hierarchical condition category (HCC) scores. More specifically, of the 44.4% of MA beneficiaries who had an HRA, HCC scores increased on average 12.8%.   

Study authors go a step further by segmenting contracts as low, medium and high, based on the HRA’s effect on risk score at the contract level. This may provide insights into HRA program design by the plan, e.g., which patients are targeted and how HRA outcomes are subsequently attached to care management.   

For nearly a decade, the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG) have expressed concern with the improper use of HRAs to inflate payments, rather than to improve care and outcomes. While HRAs can be a helpful tool for plans to identify all active conditions on an annual basis, the disconnect or “detachment” arises when diagnoses captured in HRAs are not recorded in a subsequent medical visit. This undermines the purpose of risk adjustment, which is designed to compensate plans based on the expected costs of delivering benefits to enrollees.    

Key observations 

  • The population was designated as follows: 20% low, 15% high and the remaining 64% in the medium cohort. 
  • While comprising only 15% of enrollees, the high cohort accounts for 48% of the total HRA risk-score increase. 
  • The HRA rate was much higher in the high contracts (77.9%) than low contracts (39.5%). 
  • Quality ratings favored low cohort contracts with 85% 4 stars or better vs high cohort contracts at 56%.  
  • Provider and health system integration was dramatically higher in the low vs the high contract cohort.   
  • Comparing the high and low contract cohorts, while the overall HCC score was 18% higher, medical expense was 9% lower (estimating from the plan payment and medical loss ratio values provided). 

Extrapolating on the points above, PCP-integrated risk adjustment solutions drastically reduce the risk of detached HRA outcomes and quality performance. This stands to reason because the patient’s PCP is prioritizing healthcare outcomes and management of chronic conditions, rather than focusing exclusively on code capture.     

The correlation between HRAs and coding intensity is particularly relevant given the Risk Adjustment Data Validation (RADV) Final Rule, which authorizes CMS to extrapolate RADV audit findings beginning with payment year 2018, applying the error rate from a sample, and the associated financial penalties, across a broader population of the Medicare Advantage Organization’s contract. In a RADV audit, conditions supported by a single encounter, like detached HRA visits, are at higher risk because there are no additional medical records to fall back on if there is an access, accuracy, or completeness issue with the primary record.  A PCP-integrated approach encourages follow-up care and additional documentation to support valid diagnoses.   

It should be noted that this study uses the 2020 CMS risk adjustment model.  We expect the exclusive impact of HRAs on risk scores would be tempered by as much as 40% using the 2024 risk adjustment model, which is being phased in now and will take full effect for 2025 dates of service. 

Conclusion  

At-risk entities should evaluate their current risk adjustment programs and focus on solutions that produce accurate and compliant coding accuracy that dovetail with quality and health outcomes. Legacy programs, such as retrospective chart reviews and HRAs completed by in-home assessment vendors, should be augmented with a provider-centric approach. Build a risk adjustment strategy that recognizes PCPs as partners in accuracy and quality capture, as well. PCPs are best positioned to capture all existing conditions and to address the CMS and OIG’s concerns by connecting the dots between accurate HCC capture and improved care and outcomes. 

Improve compliance and financial performance with PCP-centric risk adjustment

By Vatica Health | April 29, 2024 | Compliance, Provider, Risk Adjustment, Value-Based Care

Given the regulatory activity relating to the RADV Final Rule and 2023 Final Rate Notice, many speakers at this year’s RISE National conference referenced compliance and performance challenges. Against this backdrop, the presentation sponsored by Vatica Health was timely as it focused on how payers and providers can collaborate to improve financials results, compliance and patient outcomes.

You can view the presentation here, or read on for highlights.

Vatica CEO Hassan Rifaat, MD, kicked off the session with a market assessment. “The game has changed completely,” he noted. “You’ve got to be great, and you’ve got to be compliant. RADV is no longer a speeding ticket. It’s a big fine. There are lots of consequences for doing risk adjustment wrong.”

Rifaat called out the serious deflation in the transition from CMS-HCC model V24 to V28. Based on his experience, he noted that the best course of action is for the providers who treat the patients to code and document via an in-office program. This helps to ensure that all active conditions are captured and treated.

Experience is the best teacher

Robert Tracy, senior vice president of government programs at Independent Health Association (IHA) in Buffalo, NY, described IHA’s evolution in building a successful in-office risk adjustment program. IHA offers Medicare Advantage plans in eight counties of western New York, covering 68,000 members. IHA initially built a paper-based process connected to Annual Wellness Visits. While a significant number of members participated, providers voiced concern about the inefficiency of the paper-based process not connected to their workflows.

IHA then implemented Vatica’s solution that combines clinical resources and technology at the point of care.  Vatica’s extensive pre-visit preparation results in only vetted and validated HCC codes and care gaps being presented, setting the stage for a more effective, efficient visit. Providers appreciate the comprehensive support, which has helped drive participation to include nearly 78% of eligible providers in IHA’s network.

In the process, IHA learned that an investment in primary care is a wise decision that pays off. Patients can be educated to take advantage of the annual visit, resulting in improved care coordination and satisfaction. Tracy noted that an organization-wide effort is needed to succeed, along with a PCP-centric approach that supports PCPs and integrates seamlessly into their workflow and scheduling system.

Hear Tracy’s summary of best practices below.

A firehose of information

Vatica solves this problem by curating only validated conditions and codes, which helps the PCP make the most of their time with patients. “That pre-visit summary gets our providers thinking about not just the conditions but what care management is needed,” he explains. “It helps our providers build trust. We tell our patients that we want to identify all of their conditions so we can take great care of them.”

Charles cited a 10% improvement in risk score accuracy since the practice started using Vatica. He highlighted specific improvements in hemoglobin A1C levels and blood pressure control. In addition, the revenue generated has helped providers in multiple ways. Hear more from Charles about these services and benefits below.

The presenters agreed that in-office solutions such as Vatica should be the core of a risk adjustment strategy for payers and other at-risk entities. Solutions must support PCPs and minimize the time required, allowing providers to work at the top of their license while compensating them fairly for the work they do and the results. This will maximize compliant yield benefiting the payer, provider and patient.

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/.   

2023 recap: the year’s best content

By Vatica Health | January 25, 2024 | Compliance, Provider, Risk Adjustment

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:

Resources for providers 

Provider burnout continued to be a key issue in 2023. We provided tips for easing providers’ coding and documentation burdens here. 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/.

Partner with PCPs to maximize compliant risk adjustment yield

By Vatica Health | November 30, 2023 | Risk Adjustment, Value-Based Care

Payers are under a lot of pressure to optimize risk adjustment and compliant yield in light of the CMS Risk Adjustment Data Validation (RADV) Final Rule and Final Rate Notice issued earlier this year. A recent webinar for members of the RISE Association focused on how payers can partner with PCPs to accomplish both.  

Presenter Brian Williams, MD, is medical director of optimization at Northeast Medical Group in Mystic, Conn., part of the Yale New Haven health system. He is immersed in the system’s transition to value-based care (VBC), with 230,000 patients in shared savings or cost-sharing agreements.   

Dr. Williams was joined by Michael Rosenfeld, VP of business development for Vatica Health. Michael shared case studies from payers and providers who have benefited from collaboration to maximize compliant risk adjustment yield and close care gaps.  

You can read highlights of their discussion here or watch the webinar.

Legacy models for risk adjustment that work around PCPs, such as retrospective chart reviews and home assessments, are fraught with issues. Dr. Williams and Michael agreed that the ideal process is PCP-centric, providing dedicated resources, data and integration into the PCP’s existing workflow. Dr. Williams added that the most effective ways to engage providers are for payers to have a dedicated provider engagement staff and offer aligned incentives, provider education about clinical documentation and easy-to-use technology.

The role of provider-centric risk adjustment technology is to support the patient-PCP relationship by empowering compliant code capture, improved utilization management, patient adherence and holistic care. The technology should present high-confidence conditions from the EMR and claims data, deliver timely and actionable data and facilitate a complete and accurate coding exercise. It should not contribute to alert fatigue or require the provider to go back to the EMR to verify information. This approach improves provider and patient satisfaction and helps ensure better care coordination and the closure of care gaps.

Michael noted that working with community providers can mean multiple EMRs, limited staff and infrastructure, and competing priorities. To maximize their performance, payers can provide solutions that are easy to use and supported by clinical and administrative teams, while educating them on the importance of risk adjustment to drive optimal patient care.

Dr. Williams offered advice on how payers can assist busy PCPs on risk and quality initiatives. “It helps to have a lot of the work done before it’s presented to us. Make sure that we are working as a team. Then physicians can use their training and clinical decision making to do the assessment. Do the work that you can do as a payer,” he said. “You have to reimburse physicians for the time and effort they are spending on this work. Then make sure the clinicians have appropriate resources to help them learn to navigate whatever solutions it is.”

He cited actions that are not helpful to PCPs, including interruption to the clinical workflow, any interference of time spent with the patient, interruption of the practice’s revenue cycle or overburdening of staff.

Dr. Williams also noted that PCPs are taking on more administrative responsibilities unrelated to why they chose the profession. Payers can help make them feel valued by paying PCPs fairly and quickly and “staying in their lane,” that is, handling what is appropriate for payers to handle while not carving PCPs out of care decisions.

“A payer solution was our first real ‘toe in the water’ toward value-based care,” he noted. “Part of the success we’ve had comes from sharing the organization savings with the clinicians. They understand that the work is valuable. They take it seriously. We don’t have to force them. They’ve also become very skilled at it because they received good education and support to do this work.

“Our HCC recapture rates for fiscal year 2022 were over 95%,” Dr. Williams continued. “We have categorized our patients into seven categories of risk. We understand very clearly what patients’ risk for hospitalization and serious illness is based on which risk category they fall into. We have begun to use those risk categories to direct our resources. We’re seeing lower hospitalization rates for those patients that we’re using this algorithm for. That’s encouraging.”

Dr. Williams noted that NEMG has several payer programs in place; Vatica has the highest participation and highest user satisfaction. “It’s integrated with our EMR and that information becomes part of the patient’s care going forward.” Leveraging EMR data is critical, as many other solutions rely on claims data which can be stale and less accurate.

Vatica’s prospective solution pairs clinical staff and technology to assist physicians with coding and documentation. Clients have seen an average of 25%+ improvement in accuracy and specificity and 37% higher gap closure rate. “Our coding team reviews 100% of the information documented by providers to ensure it meets standards for clinical validation,” Michael added. “Nothing gets sent to our payer or provider partners that hasn’t been reviewed in a multi-step process to ensure that it meets compliance standards and protects our clients from audit risk.“

Michael reviewed a case study with a regional Blue Cross client that showed total incremental HCC revenue of over $100 million based on 44,600 annual encounters. It’s important to note that strong financial results are due to more accurate and complete coding and documentation.

He also shared data from a provider client who completed Vatica visits for 73% of 47,000 eligible patients in a year. During those visits, Vatica detected more than 73,000 open care gaps for physician review and helped physicians accurately identify and code diabetes with chronic complications, increasing the rate from a 4.74% baseline to 19.19% in one year.

For more information on how Vatica can help payers support PCPs to maximize compliant risk adjustment yield and quality of care, visit VaticaHealth.com.

Relieve providers’ admin burden to help combat burnout  

By Vatica Health | November 17, 2023 | Provider, Risk Adjustment

Provider burnout isn’t new. It existed long before COVID and was exacerbated by the pandemic. But it’s rising to new levels. For example, recent labor issues at Kaiser—resulting in the biggest healthcare strike in US history—were caused in part by acute staffing shortages that drive provider burnout. 

To combat burnout, healthcare organizations are raising wages. Most are strengthening hiring and retention efforts, along with a variety of other tactics. Some states are pursuing safe staffing legislation. The situation is dire and creating an impediment to achieving the CMS Triple Aim: improving patient care, reducing healthcare costs and improving population health. More recently, recognizing the importance of provider engagement and wellness, healthcare leaders have considered expanding to a Quadruple Aim to include the clinician experience. 

Ramifications of burnout 

Less common solutions to a common problem 

Aside from obvious solutions—staff recruitment and wage increases—what else can be done? 

One area of focus should be administrative burden, with physicians spending nearly 2 hours a day on EMR tasks outside work. While EMRs bring needed automation and better data, they’ve become more complex, driven by increasingly detailed and nuanced data requirements that create stress and distract from patient care. Alert fatigue is one result of this stress and distraction, which is exacerbated by vendors that send unvalidated conditions and codes directly into the EMR and physician workflow. 

Additionally, healthcare policymakers and regulators continue to mandate more documentation to demonstrate compliance with laws and standards, resulting in lengthier documentation. Value-based care (VBC) payment models, which are becoming more common, require even more clinical support, coding and documentation  to achieve performance goals. 

At Vatica Health, clients appreciate our unique model of supporting providers with clinical and admin resources. We’ve found these strategies reduce the admin burden for our provider clients and support their transition to VBC payment models as well:

  • Offer physician training on standard coding and documentation practices: get all providers on the same page in terms of process and workflows. 
  • Align physician compensation with VBC initiatives: ensuring that physicians are compensated and incentivized is paramount to obtaining physician buy-in and ongoing participation. By thoughtfully designing compensation programs for both clinical and support staff, provider groups can counter the problems of physician burnout, declining retention and shortage of physicians.  
  • Optimize the EMR and pre-encounter prep to drive efficiency and comprehensive visits: EMRs on their own do not sufficiently support coding and documentation to optimize VBC performance. Solutions are available that optimize EMR performance to help identify care gaps and facilitate accurate coding. 
  • Create better alignment with payers and advocate for programs that remove operational burden associated with risk adjustment and quality initiatives: these programs can help provider groups realize incremental revenue, improved outcomes, increased numbers of preventive health encounters and improved performance in VBC arrangements.   
  • Provide support to help physicians capture and address SDOH: successful 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.  
  • Be transparent about the financial impact of physician performance in VBC: executive leaders should share financial performance data with physicians and potentially other staff as well. Incremental revenue earned through participation in such programs can support a financially positive outcome for the group. 

A select few health plan-sponsored solutions relieve administrative burden and help improve clinical and financial performance. One example is Vatica Health, where licensed clinical nurses are assigned to each contracted practice. The nurses create a comprehensive, curated Vatica medical record for each patient encounter, presenting only conditions that are fully supported by clinical documentation. PCPs receive a streamlined, prioritized list of conditions that they can review at their convenience.  

Conclusion 

Provider group leadership should consider all viable options to address provider burnout – especially as VBC transformation creates more demands. Recruiting additional providers gets tougher as competition for fewer physicians, mid-level practitioners and nurses escalates. Finite financial resources limit never-ending wage increases. Leaders should consider out-of-the box solutions, such as payer-sponsored programs that include additional clinical and administrative resources to support providers.  

Vatica’s clinical and admin resources can reduce PCPs’ burden from coding and documentation. That not only improves provider experience but keeps the PCP central to patient care, supporting the patient experience as well. Vatica helps PCPs address chronic conditions, identify care gaps to more easily resolve them and present the most accurate picture of the patient’s condition. An accurate picture results in appropriate reimbursement, avoiding over- and under-coding that impacts overall healthcare costs. This moves us in the right direction to achieve the Quadruple Aim and gives provider group leaders concrete resources to address physician burnout. 

Five ways you can begin addressing SDOH to improve outcomes and lower costs

By Vatica Health | October 20, 2023 | Risk Adjustment, Value-Based Care

It’s an inescapable fact: The lower a person’s socioeconomic position, the worse their health. Research by the World Health Organization (WHO)  has shown that non-medical factors—such as education, employment, food insecurity and housing—have a significant impact on the health disparity between rich and poor. In fact, it is estimated that up to 89% of the factors that  influence health exist outside of medical care. These factors are known as Social Determinants of Health (SDOH).

Government agencies and healthcare providers alike understand the impact of SDOH and want to do something to close the gap. However, a 2022 survey showed that while 80% of care providers believe that addressing SDOH is essential to improving health outcomes and decreasing costs, 61% said they lacked the time and the ability to affect the SDOH of their patients.

If, like the care providers surveyed, you’re committed to addressing SDOH but feel ill-equipped to make a difference in the near term, read on to begin making progress against your SDOH goals.

Below are a few tactics to consider, which are more fully described in a recent white paper, “Five ways you can begin addressing SDOH to improve outcomes and lower costs.”

Identify people in need and collect the data

Social screening needs to be a component of every patient visit. Screening tools, available through some EMRs and other sources, can help identify people in need within your patient population.

Master the codes

To ensure your clinicians and coders are up to date on the new Z codes, consider designating one staff member as your in-house SDOH expert and charge that person with following, disseminating and training colleagues on that information as it is updated.

Leverage payer resources

Health plans are also offering more direct SDOH support. For example, Anthem’s Member Connect program guides Medicare Advantage members to community health workers who help them find the community resources they need. This has increased healthcare engagement for 74% of members, resulting in an 8% reduction in hospital admissions and a 43% reduction in ER visits.

Build relationships with community resources

To drive better outcomes, it’s vital to connect patients to governmental and community resources that can help address their SDOH issues.

While referring patients to the appropriate programs is a good start, it is not enough; you should follow up to ensure they’ve made those connections. For that reason, it’s to everyone’s benefit for you to get to know and partner with community-based organizations (CBOs) to share information, ideas and issues and ensure referrals are followed up.

Emulate the successful methods of other care providers

The experiences of other providers may offer valuable lessons on what works and what doesn’t. For example, the University of Pennsylvania Health System discovered that offering patients a complimentary ride to an appointment did not lower patients’ 36% no-show rate. However, NorthPoint Health & Wellness Center  of Minneapolis  has seen success over the past 15 years by providing patients with bus tokens and hosting lunches with religious leaders of underserved communities. These and other actions have enabled NorthPoint to more than double vaccination and health screening rates to nearly 80%.

Addressing SDOH makes an impact

Taking proactive measures as described here will inform better decision-making and drive policies that work to undo the inequities in healthcare and lower costs for everyone. And when you build on those findings, using analytics to identify at-risk or in-need individuals, you can take the next step with outreach efforts that refer patients to relevant professionals and community resources.

Vatica Health can help. Our PCP-centric risk adjustment and quality of care solution combines technology with clinical consultants who review and curate all relevant health plan and EMR data. This results in a pre-visit notification that can help your team efficiently perform the visit, document patients’ health status and assist with care gap closure.

Interested in a more in-depth look at SDOH resources? Click here.