Category: Risk Adjustment

A new paradigm in risk adjustment – a shift from collecting codes to impacting care

Development of risk adjustment strategies is often complex and involves input from stakeholders across multiple cross-functional teams. Quality, finance, compliance, operations, and other teams are all stakeholders in the decision-making process. Managed care organizations strive to deploy effective, comprehensive risk adjustment solutions which requires taking into account a number of considerations: effectiveness, regulatory compliance, and patient and provider satisfaction.

When considering the various options available to health plans, there is an emerging trend to shift from retrospective and home assessments to PCP-centric prospective programs. There are a few reasons for this change. Given the established relationships patients have with their PCPs, prospective programs are often the most effective method for addressing gaps in care and ensuring alignment between medical record documentation and coding to the highest degree of specificity. Prospective programs permit real-time alerts of previously diagnosed conditions as well as those that are suspected. The ability to impact outcomes, at the point of care, is powerful.

In contrast, legacy models have very little impact on care and outcomes.  Retrospective review programs deploy teams of coders to review charts and capture codes after the patient encounter has occurred. This backward-looking approach is not only abrasive and disruptive to providers, it is also ineffective in terms of impact on quality of care and patient outcomes.

Home assessments, while prospective in nature, are abrasive and invasive to patients. They are performed by clinicians that typically do not have an existing relationship with patients and do not have access to the EMR where the most valuable clinical information is stored. Furthermore, continuity and coordination of care is often non-existent in that follow-up care is not guaranteed. In fact, a September 2020 report from the Office of Inspector General (OIG) expressed this key takeaway: “Billions in estimated risk-adjusted payments supported solely through HRAs [health risk assessments] raise concerns about the completeness of the payment data, validity of diagnoses on HRAs, and quality of care coordination for beneficiaries.”

The shift from antiquated programs that simply center around collecting codes to PCP-centric initiatives has been accelerated by certain actions and comments made by the Centers for Medicare and Medicaid Services (CMS). Beginning in 2017, CMS began to gradually revise its methodology for calculating beneficiary risk scores to increasingly rely on encounter data. By 2022, the expectation is that the Part C risk score would rely entirely on encounter data. The benefit of encounter data is that it validates the source of the data to ensure that it appropriately meets program requirements. Said differently, validation of treating providers, type, and place of service. These requirements are best addressed through the use of prospective risk adjustment programs.

CMS officials have also been critical of home assessments, previously stating the following: “There appears to be little evidence that beneficiaries’ primary care providers actually use the information collected in these assessments or that the care subsequently provided to beneficiaries is substantially changed or improved as a result of the assessments. Therefore, we continue to be concerned that in-home enrollee risk assessments primarily serve as a vehicle for collecting diagnoses for payment rather than serve as an effective vehicle to improve follow-up care and treatment for beneficiaries.”

In limited circumstances retrospective chart review and in-home assessment programs may be considered as part of an overall risk adjustment portfolio. However, such programs must be carefully and thoroughly evaluated and should only be utilized to address situations where an in-office prospective program is not a viable option.

A well-designed health plan-sponsored risk adjustment program should be easy to implement and very beneficial to PCPs. To do so requires a combination of powerful technology and comprehensive in-office support that seamlessly integrates with physician workflows. It also requires documentation and coding validation and provider education. When health plans and providers partner on risk adjustment and quality programs, great things happen: superior RAF yield, enhanced provider satisfaction that drives revenue and VBC performance, and better clinical outcomes.

Documentation, coding, and revenue: What every physician needs to know about HCCs and 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. Here are five questions and answers to consider.

Why does provider documentation matter for risk adjustment?

The provider—through their documentation—tells the patient’s story using the ‘language’ of ICD-10-CM diagnosis codes. Together, these codes create a narrative that includes important diagnostic information. When combined with demographic data and other details, the patient’s health status becomes clearer. Without this narrative, the story is disjointed, confusing, or lost completely. Health plans, CMS, and other treating providers can’t connect the dots when there are only a few dots to connect, or worse yet, a blank page.

If your documentation doesn’t support the ICD-10-CM codes you’ve assigned—or you omit certain codes because no documentation exists—your revenue under value-based contracts could suffer. 

Why does coding matter for risk adjustment?

If your coded data indicates subpar performance or that you haven’t met certain performance thresholds, you could be missing out on revenue. Inadequate coding (i.e., missing codes or lack of specificity) also often leads to time-consuming onerous retrospective chart retrieval and reviews as well as compliance risks.

For patients, lack of appropriate ICD-10-CM diagnosis codes can result in poor coordination of care. This is true under all payment models—not just risk-adjusted ones. That’s because documentation and coding are the primary means of communication between care teams. In addition, patients may be omitted from beneficial care management, disease intervention, and other wellness programs if the coded data associated with their records is inaccurate or incomplete. Strong documentation, combined with appropriate ICD-10-CM coding, provides a comprehensive view of the patient. This ultimately helps control the cost of care.

For the purposes of this article, we’ll focus on the Centers for Medicare & Medicaid Services’ (CMS) risk adjustment model.

Not every ICD-10-CM diagnosis code affects risk adjustment under the CMS model. That’s because this payment 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 mean 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).

HCCs paint a complete picture of each beneficiary’s acuity to ensure appropriate and accurate reimbursements, effectively managing costs for high-risk members and delivering high-quality care.

Check out the example below that illustrates a $15,000 difference in payment under the CMS-HCC model based on whether the provider captures these four diagnoses with maximum specificity: Type 2 diabetes mellitus with a manifestation of stage IV chronic kidney disease, long-term insulin use, and chronic obstructive pulmonary disease.

Impact of Accurate Documentation & Code Capture

What are some documentation and coding best practices for busy physicians?

Consider these tips:

  1. Perform a valid face-to-face encounter. As a result of the ongoing impact of the COVID-19 pandemic, synchronous audio and video appointments are, for the time being, acceptable for the purposes of risk adjustment.  
  2. Use the ‘MEAT’ acronym as a best practice guide for documentation:
    • Monitor: Document signs and symptoms as well as any disease progression or regression. Don’t forget to evaluate chronic conditions at least once annually. Also, avoid use of ‘history of’ if the condition remains active.
    • Evaluate: For example, document test results, medication effectiveness, and response to treatment.
    • Assess: For example document any of the following, when relevant: Ordering of tests, discussion, reviewing records, and counseling. Copying and pasting the entire problem list into the assessment and plan is unacceptable.
    • Treat: For example, document any medications ordered, therapies, or other modalities.
  3. Link diagnoses with manifestations using a linking statement or other document.
  4. Add all diagnosed conditions to both the chronic problem list and assessment.
  5. Submit all relevant ICD-10 diagnosis codes, including Z codes.
  6. Ensure the medical record includes a legible signature with name, date, and credentials.
  7. Ensure the diagnoses being billed match the actual medical record documentation.
  8. Always remember the golden rule of medical record documentation: If it’s not documented, it didn’t happen.

How can physicians minimize compliance risk and benefit from risk-adjustment programs?

One way to minimize risk and to actually 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.

Leverage health plan-sponsored programs to combat physician burnout

The statistic is striking: 42% of physicians report feeling burned out. That’s according to a 2021 national survey conducted by Medscape that included more than 12,000 physicians across 29 different specialties. Interestingly, 79% of physicians said this burnout started before the current COVID-19 pandemic with the majority (58%) citing ‘too many bureaucratic tasks’ as the number one reason. While it is too early to measure directly, we anticipate that the COVID-19 pandemic will exacerbate this critical problem, further amplifying the mental, physical, emotional, and financial strain physicians were previously experiencing.

Why is physician burnout dangerous?

First, physician burnout is associated with higher rates of major medical errors. Physicians who are burned out may be less likely to identify and address all of a patient’s chronic conditions, thereby missing out on opportunities to improve outcomes. In addition, it can potentially lead to access challenges as physicians who experience burnout ultimately reduce time spent on direct patient care. The personal effects of physician burnout are also concerning: Increased risk for cardiovascular disease and shorter life expectancy, problematic alcohol use, broken relationships, depression, and suicide. Finally, it can negatively affect patient satisfaction.

The challenge: Increasing administrative burden, inadequate support

There’s no denying the fact that bureaucratic tasks, such as increasing documentation requirements, fuel physician burnout. According to a recent survey, clinical process design and the clinical structure, both of which are highly impacted by EHRs, contribute to approximately 40% of clinician stress. EHR complexity driven by increasingly detailed and nuanced data requirements, creates stress and distracts from patient care.

Healthcare policy makers and regulators continue to mandate even more documentation to demonstrate compliance with laws and standards. The advent of value-based payment models necessitates incremental documentation and workflows to achieve performance goals. Additionally, significant administrative efforts are often required to obtain prior approvals for certain treatments and prescription medications. These tasks are time-consuming contribute to physician burnout. According to a physician survey conducted by the National Institutes of Health (NIH), on average, 24% of working hours were spent on administrative duties.

The solution: Simplicity, support, value, and flexibility

For an immediate impact, health systems and individual physicians can turn to health plan-sponsored programs that improve both clinical and financial performance. Some of these programs supply free clinical and administrative resources and assist with performance in value-based arrangements to yield financial incentives.

Vatica Health is one example. Vatica takes a physician-centric perspective, meaning the physician and clinical workflow are the central focal point of the program. With a keen focus on process simplification and efficiency, Vatica Health focuses on minimizing the amount of time and effort required of physicians. All aspects of the physician experience are designed to yield maximum value with the least amount of effort.

Vatica assigns licensed clinical nurses 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. The result is that the physician is presented with a streamlined and prioritized list of conditions for review that they can complete at their convenience. Organizations participating in Vatica’s program realize incremental revenue, increases in the utilization of preventive health encounters (e.g., Annual Wellness Visits), and improvement in overall performance in value-based care arrangements.

There are also other ways to address the troubling dynamic of physician burnout and there are many resources currently available online. For example, the Well-Being Playbook 2.0—provided by the American Hospital Association (AHA) and AHA Physician Alliance, includes links to various webinars, podcasts, and case studies. The American Medical Association also provides a variety of articles that can help physicians experiencing burnout.

Taking the first step toward addressing physician burnout can have a long-lasting impact that benefits the entire healthcare ecosystem. Vatica will continue to do its part to raise awareness of this problem and lends its support to the collective, coordinated actions being taken across the industry to address the underlying causes of burnout.

About Vatica Health

Founded in 2011 as the first preventive services technology solution designed specifically for physicians, by physicians, Vatica Health remains a pioneer in physician-centric technology and support solutions that directly improve clinical outcomes, efficiency, and financial performance. Vatica Health deploys licensed, clinical nurses (on-site and virtually) that serve as extensions of your team at no cost to the practice. Practices retain all fee-for-service payments generated from the encounters, and they also receive incremental incentives for completion of the signed Vatica encounter.

The best part?

It’s a health-plan sponsored initiative. That means it’s completely free for practices to participate.

As practices continue to seek point-of-care solutions to better tell each patient’s story and improve outcomes, they need look no further than Vatica Health. 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/.

Don’t let chronic conditions be an afterthought when using telehealth

If there’s one silver lining to COVID-19, it’s the rapid adoption of telehealth that enables physicians to take care of patients while also limiting the spread of the virus. The Centers for Medicare & Medicaid Services (CMS) even expanded its list of telehealth-covered services during the public health emergency, allowing physicians to render certain preventive care, evaluation and management of conditions, and other services without requiring patients to come into the office.

One unintended consequence?

When using telehealth, physicians may be less likely to capture chronic conditions that affect risk-adjusted payments. Why? Lack of time, new workflows, and a variety of other causes.

This is detrimental to risk adjustment for two reasons. First, it can affect the quality of patient care—particularly during care transition when documentation becomes critical. Patients who benefit the most from remote care during the pandemic are often those that tend to have multiple chronic conditions. However, it is still critically important to capture patient complexity through appropriate documentation and coding.

Second, it negatively affects physician reimbursement under capitated or risk-based payment models. When documentation and medical codes don’t paint an accurate picture of patient severity, physicians receive fewer resources for those patients who are inappropriately perceived to be less clinically complex. The same is true for government-sponsored payers.

The good news is that a comprehensive risk adjustment and quality solution can help by taking some of the administrative burden off physicians so they can concentrate on providing high-quality patient care. The first step, though, is to address common myths about telehealth in a value-based care environment.

Below, we address three myths about telehealth as well as strategies to help physicians depict a more accurate picture of patient severity, acuity, or complexity when using this technology.

Myth: ‘I only have time to focus on the acute problem during a telehealth visit. I can’t possibly capture chronic conditions as well.’

Truth: Although physicians are often pressed for time during an encounter, it only takes a few seconds to check in with the patient about the status of their chronic conditions. It can be as simple as asking the patient whether they are taking their medications as prescribed for each chronic condition.

Physicians can also participate in health-plan sponsored risk adjustment and quality of care initiatives that can help them report the quality of care they normally provide. These initiatives provide clinical and administrative support to ensure accurate and comprehensive documentation and coding so physicians can spend more time on direct patient care.

Myth: ‘It’s too difficult to provide an Annual Wellness Visit (AWV) via telehealth. Care quality will suffer.’

Truth: In a recent survey, 49% of physicians cite ‘diminished quality of care’ as a top reason why they haven’t provided a virtual consultation. However, decreased care quality with telehealth isn’t yet proven, and for some patients, it may be the only way to get them in the door—albeit a virtual one. The AWV is an opportune time to capture and manage chronic conditions. During COVID-19, this is more important than ever as these diagnoses may place patients at higher risk for developing complications if they were to contract the virus.

Deferred care during COVID-19 has become all too common. Four in 10 U.S. adults reported avoiding medical care because of concerns related to COVID-19. One recent survey found that patients with chronic conditions are less engaged and that fewer patients are seeking preventive care. This means chronic conditions could go undetected and unmanaged for months at a time. There may also be missed opportunities for routine vaccinations or early detection of new conditions, both of which could result in poor patient outcomes.

Health-plan sponsored risk adjustment and quality of care initiatives help physicians efficiently provide critical preventive care services without jeopardizing the time spent on patient care.

Myth: ‘Telehealth won’t help me succeed under value-based payment models. It’s too risky to embrace this new technology knowing that my revenue could suffer.’

Truth: Telehealth is in no way a barrier to value-based care. In fact, it enhances value by increasing patient access and providing physicians the platform to capture and address chronic conditions.

In fact, more than 75% of clinicians responding to a recent survey said telehealth enabled them to provide quality care for an array of conditions and situations: COVID-19, acute care, chronic disease management, hospital follow-up, care coordination, preventative care, and mental/behavioral health. Additionally 60% reported that telehealth has improved the health of their patients, and the majority would like to continue to offer telehealth visits following the pandemic.

With the help of health-plan sponsored clinical and administrative support, physicians can use telehealth to improve quality care reporting while also supporting revenue integrity through accurate and complete data capture.

How Vatica Supports Providers

Physicians providing care via telehealth need extra support. Our team deploys on-site or virtual clinical consultants with backgrounds as RNs, LPNs, or PAs that serve as extensions of your team at no cost to the practice to help surface important items to address with paitents in a virtual or in-office setting, such as chronic condition management. Practices retain all fee-for-service payments generated from patient encounters and also receive incentives for coding visits.

The best part? It’s a health-plan sponsored initiative. That means it’s completely free for practices to participate. Learn more about how Vatica can help your practice.

Telling the patient’s story during COVID-19: Primary care challenges and long-term solutions

When the COVID-19 pandemic first struck, small independent primary care physicians were among the first providers to feel the impact. Patients cancelled appointments out of fear or necessity. Practices shut down temporarily to comply with shelter-at-home orders. As with many businesses, some practices eventually closed their doors for good because they simply couldn’t weather the storm financially. As the pandemic raged on, even larger, system-owned practices began to feel the wrath of COVID-19. Today—nearly a year later—entire health systems both large and small are feeling the strain.

Despite these unprecedented challenges, providers have tried not to lose sight of the most important goal: to provide high-quality patient care that drives optimal health outcomes and supports the transition to value-based care.

How can they do that?

Ensure accurate and complete documentation that reflects each patient’s clinical story. Document all current and emerging chronic conditions to the highest degree of specificity. Administer all age-based or seasonal screenings and vaccines that affect health and functioning, or refer patients for these services. Encourage preventive care and behavior modification to support a healthy lifestyle.

As we look ahead, organizations must confront an ongoing shortage of primary care physicians and nurses, as well as a virus-fearful patient population that may be difficult to engage in preventive health. The ‘old way’ of addressing gaps in patient care (like during an in-person visit with a physician) probably isn’t realistic anymore. It’s time to rethink strategies and address ongoing challenges.

Following are four challenges every healthcare organization must address, along with potential solutions to ensure high-quality patient care and revenue integrity.

Challenge #1: There aren’t enough physicians working in the practice setting.

An increase in hospital admissions—including admissions for patients with COVID-19—has forced health systems in rural and urban areas to re-deploy employed physicians and their nursing staff into acute care units. With fewer providers working in the office setting comes diminished appointment availability, including appointments for preventive health. This comprehensive annual visit is a critical opportunity to identify conditions that warrant ongoing monitoring. Without this touchpoint, care gaps can easily occur. The patient’s clinical story remains largely untold, and performance in value-based care arrangements may be jeopardized.

Solution: Think outside the box.

It’s understandable that physicians are distracted by other responsibilities; however, it’s also critical that they not lose sight of reviewing patients’ chronic conditions annually. That’s where they may need help. Some have contemplated hiring a physician assistant, for example, but are hesitant to make the financial investment out of fear that patient volume won’t cover the person’s salary and benefits. The good news is that there may be other options. For example, the practice could consider participating in a health-plan sponsored program that provides clinical and administrative staff for support. Going this route prevents care gaps, reduces overhead costs, and slows the spread of COVID-19. As an added benefit, there is often a financial incentive offered for completing patient encounters.

Challenge #2: Some patients still fear coming into the office.

Even despite stringent COVID-19 protocols, many patients continue to feel that the risk of coming into the office for preventive and routine care isn’t worth it. Four out of every 10 U.S. adults say they’ve avoided medical care because of concerns related to COVID-19.

Solution: Telehealth (with patient tutorials).

Telehealth helps practices keep patients happy and safe. However, there’s one caveat: it might take a little effort to help older adults learn to use this technology. More than a third of adults over age 65 face potential difficulties seeing their doctor via telemedicine. Proactively educating patients on how to use the telehealth solution and supporting their utilization can go a long way in terms of engagement. Administrative support often includes the use of Patient Engagement Representatives to contact patients to schedule appointments, deliver appointment reminders, and educate them on telehealth tools.

Challenge #3: Patients may no longer prioritize preventive health.

During COVID-19, many patients have deferred routine and preventive care. Perhaps they lost their insurance or faced another type of financial hardship—or the physician they always saw is no longer available. Some may have even gravitated toward the idea that they don’t need a doctor because they’re able to self-diagnose using the internet. Routine and preventive health falls to the bottom of the priority list, which is especially critical for patients diagnosed with chronic conditions.

Solution: Educate patients.

Practices must be able to convey the value of preventive and routine health services. Preventive care helps physicians diagnose diseases earlier, which often results in better outcomes and lower cost of care. Routine care prevents exacerbations, reduces symptoms, and improves quality of life. Practices must be able to engage patients on a personal level while also explaining that many of these services may be covered at 100%. This education empowers patients to make the best decisions for their health.

Challenge #4: Physicians are burned out, and revenue is declining.

Forty-seven percent of family medicine physicians and 46% of internal medicine physicians say they’re burned out, and it isn’t surprising why: long and busy workdays, time pressures, and ever-increasing administrative demands. COVID-19 has exacerbated this dynamic and led to a sharp decline in patient volume that has threatened the financial viability of many PCP practices.

Solution: A comprehensive Risk Adjustment and Quality solution.

Participating in health-plan sponsored risk adjustment and quality of care initiatives can help PCPs who are struggling to close revenue and care gaps. PCPs are already overworked and dealing with the cascading effects of COVID-19. It’s critical to find a partner that provides dedicated clinical and administrative support services to reduce administrative burdens, engage patients, and improve health outcomes. The result? Increased utilization of preventive health encounters and improved financial and clinical performance in value-based care arrangements.

How Vatica Supports Health Systems

As practices continue to seek point-of-care solutions to better tell each patient’s story, they need look no further than Vatica Health. We’re accelerating the transformation to value-based care by helping providers, health plans, and patients work together to achieve better outcomes. Our team deploys on-site or virtual clinical consultants with backgrounds as RNs, LPNs, or PAs that serve as extensions of your team at no cost to the practice. Practices retain all fee-for-service payments generated from patient encounters and also receive incentives for coding visits.

The best part? It’s a health-plan sponsored initiative. That means it’s completely free for practices to participate. Learn more about how Vatica can help your practice.

How to succeed in value-based care with service-enabled technology

More and more primary care providers (PCPs) are entering value-based care arrangements, whether by choice or mandate. In fact, CMS hopes to have 100% of Medicare Advantage payments linked to alternative payment models by 2025.

With this new approach to care, it’s important for PCPs to understand the impact that risk adjustment and quality of care has on value-based care performance and assess whether their organization has the building blocks in place to ensure success. Unfortunately, PCPs are frequently impeded by insufficient time, data, and staffing resources, which prevents them from reaching their clinical and financial goals under these emerging payment systems. However, PCPs who address these gaps by evaluating their practices’ strengths, opportunities, and partnership needs are well-positioned to thrive in value-based care.


Risk Adjustment and Quality of Care

As we move to value-based care, providers will be compensated based on efficiently delivering better results—not more procedures. Value-based care is designed to incentivize providers to improve outcomes in a cost-efficient manner. In other words, payment and quality of care are inextricably linked.

Two critical components to any value-based care arrangement are risk adjustment and quality reporting. This is because success in value-based care depends on accurately assessing the clinical needs of your population, and reporting these needs so that your payments will be sufficient to deliver appropriate care.

The challenge is that risk adjustment and quality reporting is labor intensive and is predicated on a complex set of rules, which frequently becomes a stumbling block for practices. Because of the complex payment methodology associated with risk adjustment, appropriate coding specificity is needed to accurately report chronic conditions. Without this specificity, plans and PCPs may end up with artificially low patient risk scores, resulting in insufficient funds to deliver adequate levels of care. Similarly, PCPs must adhere to the reporting standards for quality gap closures, and deviation can result in sub-standard outcomes.

For practices that lack specialized coding and quality technology, as well as properly trained staff, keeping up with these activities is a significant challenge.


What to Look for in Service-Enabled Technology

More often than not, PCPs attempt to solve these challenges with the aid of technology. However, as many PCPs know, the implementation of new software can create more problems than it was intended to solve. With office staff burnout at an all-time high, it is important to make sure that any new tools being utilized are supporting, not hindering, the team’s success.
What should PCPs be looking for when selecting the right partner? Let us look at some common quality reporting and risk adjustment challenges and how your technology should address them.

Provider Documentation Support
Challenge: Due to lack of coding expertise and ineffective technology, provider documentation is often not specific enough to support the ICD-10 coding necessary to accurately risk adjust a patient. Many common chronic conditions, such as major depressive disorder, specified arrhythmias, staged chronic kidney disease, and others, can only be risk adjusted when specified in physician documentation.
Solution: This level of detail can be achieved with a combination of clinical decision support, computer-assisted diagnostic coding technology, and supplemental clinical staff. Because technology alone cannot eliminate these challenges, augmenting existing staff with clinical resources to supplement these technology solutions, commonly known as service-enabled technology, is emerging as a gold standard.

Coding Expertise
Challenge: Risk adjustment payment methodology is highly complex. While PCPs may have medical coders on staff, they often lack the specialized skills needed to code to appropriate specificity. To bridge this gap, health plans deploy vendors to perform either home assessments or retrospective chart reviews, which can cause patient and provider abrasion.
Solution: PCPs can avoid these pitfalls with EMR-integrated technology that is powered by algorithms that do the heavy lifting by surfacing the most specific and relevant codes. Because an accurate and complete data set for each patient is critical, providers should consider supplemental clinical staff to support provider documentation with the EMR to synthesize it with health plan data.

Seamless Quality Reporting
Challenge: Quality of care programs can be challenging for providers in value-based care arrangements. Providers often lack the data and tools to support the reporting and activities associated with these measures.
Solution: Providers should consider solutions that specialize in quality reporting to foster greater communication and collaboration with health plans. New service-enabled technology solutions change the way health plans and providers are working together to improve financial and clinical results.
In a nutshell, technology alone is insufficient. Providers need both powerful EMR-integrated technology wrapped with clinical and administrative support to drive superior value-based care performance. PCPs do not need another application to log into—they need a team of experts behind the screen helping the technology work for them.


To learn more about Vatica’s PCP-centric solution for Risk Adjustment Coding and Quality of Care, click here.

Patient care in an ongoing pandemic: Challenges and solutions

At the start of the COVID-19 pandemic, we braced for a few turbulent weeks, which has since evolved into months of uncertainty with no end in sight. No one anticipated the extended timeline or the effects it would have on the healthcare ecosystem, especially on primary and preventive care. Primary care practices (PCPs) continue to be burdened by the daily challenges caused by the pandemic. Visit volumes may be rebounding, but some populations are still deferring routine or planned care. Revenue is ticking northward again, but value-based care outcomes may be lagging. Preventive care is back at the forefront, but months of unmanaged conditions are catching up.  

Fortunately, there is good news. As primary care practices continue to weather the ups and downs of the pandemic, there are some solutions available to help them navigate these ever-changing tides. 

While some of the challenges PCPs faced early in the pandemic have faded into the background, others have emerged or settled to become a new commonplace element of patient care. 


Navigating telehealth

Challenge: In the first few months of the pandemic, stay at home orders and practice closures were widespread, resulting in a dramatic decline in patient visits. Providers experienced record-low visit volumes in March and April, with outpatient visits declining nearly 60% by early April. Telehealth boomed to address this unprecedented disruption to the healthcare system. A Phreesia report found telehealth activity peaked at 13.8% of total patient visits in mid-April. While the proliferation of telehealth was a game changer during the early days of the pandemic, it cannot replace the treatments and procedures which require an in-office visit—especially for seniors with several chronic conditions who may not have the ability to leverage telehealth technology.

Solution: Telehealth is a great way to extend the PCPs’ reach, but it’s not a panacea. Telehealth is an efficient and cost-effective way for providers to deliver certain types of care, address routine questions, and maintain patient engagement. It can also be part of a comprehensive strategy to improve quality of care and coding. Moving forward, a hybrid of both in-person and telehealth care will be needed to meet the needs of a practice’s varied patient population.  


Emphasizing chronic care management 

Challenge: The pandemic has precipitated a decline in in-person ambulatory care and, as a result, research suggests that there has been a decline in chronic disease management. Neglecting care management for chronic conditions has a domino effect, as today’s missed routine visit can lead to a future hospitalization. Performance on value-based care arrangements may also be impacted. 

Solution: Patients with chronic conditions must receive routine care to avoid an acute care crisis. The situation is especially critical for seniors, since more than two-thirds of Medicare beneficiaries have two or more chronic conditions, which exacerbates the risks associated with COVID-19. To actively manage your patients’ chronic care conditions, providers should consider a combination of in-office visits, telehealth, and remote patient monitoring devices.


Creating patient engagement

Challenge: Even after the initial shock of the pandemic has dissipated, many practices remain short-staffed, resource constrained, and under considerable financial pressure. This has made it difficult for providers to maintain a high-level of patient engagement, which is difficult under the best of circumstances.

Solution: More than ever, PCPs must be vigilant about communicating with patients so preventive measures and routine care don’t fall by the wayside. Integrating new methods of communication with traditional outreach can help improve patient engagement and visit volume.


Treading unstable revenue

Challenge: While patient volume has rebounded for many practices, the impact of lost revenue remains a formidable setback. An October Primary Care Collaborative survey revealed that only one-fifth of PCPs said revenue is within 10% of pre-COVID-19 levels.

Solution: PCPs should be mindful of opportunities that improve their clinical and financial performance, such as participating in health-plan sponsored quality of coding and care initiatives. Risk adjustment has often been considered a problem only payers look to solve, but by implementing a quality of care and coding solution, providers can achieve many important and desirable clinical and financial benefits.


The Path Forward: A Turnkey Solution

PCPs need turnkey solutions to help them optimize their practices during these unprecedented times. Vatica Health’s solution leverages a team of expert clinicians and powerful technology to help you—the PCP—optimize outcomes and performance. Our platform is easy to use, EMR-agnostic, and designed for point-of-care use. The process is simple and won’t interrupt your workflow. 


  • Vatica provides on-site or telehealth clinicians who handle 90%+ of the work, so you can focus on patient care.
  • The Vatica platform synthesizes health plan, EMR, and patient-reported data to create a comprehensive view of the patient and applies advanced algorithms to facilitate enhanced diagnostic coding.
  • Vatica’s teams assist with patient engagement and administrative tasks. 
  • Post-visit, you review relevant codes and sign the Vatica encounter—all in less than 10 minutes.
  • Our team of AAPC CRC™ certified clinical coders review 100% of coding and documentation for completeness and accuracy.

At Vatica, we take our role as a PCP-centric solution provider seriously. We are dedicated to improving coding accuracy, quality of care, patient engagement, and ultimately your clinical and financial performance. We are prepared, and willing, to support your practice through this global pandemic and into the future. 

Improving quality of care and coding: The road less traveled to value-based care

Q&A with Vatica Health Co-Founder, Dr. Averel Snyder

At Vatica, we pride ourselves on being a company founded by physicians for physicians. Dr. Averel Snyder, a cardiothoracic surgeon, cofounded Vatica in 2011 after becoming frustrated with the mounting challenges physicians were facing. He set out to create a unique PCP-centric model that places providers in the driver’s seat of improving both quality of care documentation and practice revenue. We recently spoke with Dr. Snyder to discuss why he started Vatica and how risk adjustment and quality initiatives fit into broader, and timelier, industry issues including value-based care, the role of the PCP, and the COVID-19 pandemic.

There are not a lot of companies that solely focus on enabling physicians to perform risk adjustment coding and quality of care initiatives. What inspired that for Vatica?

It’s a funny story. Steve, my co-founder, and I initially started Vatica nearly a decade ago to enable physicians to more efficiently deliver the newly created Medicare Annual Wellness Visit. We knew that once we helped providers improve care and practice revenue, we could offer more comprehensive solutions. A couple of years later, I was attending a healthcare conference, listening to the CEO of a home assessment company boast about the benefits of his organization versus alternative methods of capturing diagnostic codes for the purpose of risk adjustment. He stated emphatically that their model was the best method for optimizing risk adjustment coding and stratifying patient risk, which enabled their health plan clients to accurately predict the costs on which their capitated payments are based. As he spoke, I felt myself becoming more frustrated by the minute because his claims seemed unfounded.

Immediately, I thought, this isn’t fair or accurate for a few reasons. First, PCPs are inappropriately being cut out of the financial and care loop. Second, it’s not in the patients’ best interest to be seen by a clinician with whom they have no relationship with and who does not have access to their complete medical record. Third, I wondered how non-PCP affiliated nurses were closing clinical and quality care gaps.

I went home and began to research the Medicare Advantage industry and quickly found that my concerns were justified—CMS also began to scrutinize the value of home assessments that failed to improve care and outcomes due to the lack of integration with the PCP.  

I had the proverbial light bulb moment. It struck me that we should empower physicians to use a simple interface to perform risk adjustment coding and capture quality of care data in a way that also improves their practice’s financial performance. I knew this could address an important pain point that most physicians feel—being overworked and underpaid. Plus, I knew that the treating physicians could do this work with greater efficiency and quality, leading to improved patient outcomes.

Fortunately, this insight, unlike many of my other entrepreneurial ideas, proved accurate, and nearly a decade later we have empowered thousands of PCPs to “take back” risk adjustment assessments. In doing so, we’ve helped improve outcomes and generated tens of millions of dollars for our provider network.

What makes Vatica’s solution different?

As a busy practicing physician for over two decades, I think I have a good sense of what frustrates providers—too many administrative burdens, not enough time, and declining income. We designed our solution with these frustrations in mind. We provide dedicated clinical support services to reduce administrative burdens, we negotiate health plan incentives to enhance PCP revenue, and improve quality by increasing the use of preventive services and helping to close care gaps. It’s a win-win-win—providers, health plans, and patients all benefit.

Why is it important to put PCPs at the center of risk adjustment?

I feel strongly that the PCP should be at the center of care. The treating PCP and their staff—not some randomly assigned clinician—is best suited to have the most efficient and effective face-to-face encounter with the patient. Given their relationship with the patient and access to all clinical information in their EMR, they are the most appropriate clinician to accurately document and code clinical conditions and close care gaps leading to better outcomes.

Talk to us about how Vatica helps PCPs succeed in value-based care.

Value-based care is about efficiently providing the highest quality of care to improve outcomes. There are a number of studies that demonstrate physicians in value-based care programs provide higher quality of care. Unfortunately, many PCPs lack the technology, expertise, staff, time, and other resources to thrive in value-based care. Vatica addresses this issue head-on. Unlike a lot of other solutions, Vatica is not here to make more work—we actually do 90% of the work for PCPs.

Vatica’s solution not only facilitates risk adjustment documentation and coding—but also enables PCPs to close gaps in care and increase the utilization of preventive services which are critical to improving outcomes. Powered by our technology platform, PCPs accurately capture all the active medical conditions with the associated documentation for clinical validation in the medical record. Vatica’s clinical consultants leverage all available data to create an accurate and complete view of the patient—the key to improving outcomes and performance in value-based care.

Why are risk adjustment and quality of care initiatives important to primary care providers?

Value-based care is designed to incentivize providers to improve outcomes in a cost-efficient manner.  Finances and quality of care are inextricably linked. Success in value-based care depends on accurately assessing the needs of your population so that your payments will be sufficient to deliver appropriate care. And for PCPs, this should be an urgent initiative since each year alternative payment models shift more risk to providers. I’ve heard providers say, “When value-based care comes, then I will pay attention to risk adjustment.” But, then it’s too late. The CMS data collection lags approximately three years, so your allocated resources for patient care in 2021 may be dependent on your coding and documentation in 2018. The time to focus on it is now.

What are the compliance risks for PCPs and health plans with other risk adjustment and quality of care solutions?  

In a standard risk adjustment data validation audit for a health plan, a meaningful percentage of the submitted diagnosis codes will be unsubstantiated in the medical record. Most of the approaches to risk adjustment are not meeting the new standard, which requires clinical validation. As a physician, it was important for me to design a solution that improved efficiency and mitigated compliance risk for providers. To accomplish this goal, we aggregate all available clinical data from the EMR and present all active medical conditions and their associated documentation for clinical validation to the treating provider. The provider is then responsible for selecting an appropriate ICD-10 code and completing “TAMPER” documentation. Then, as a fail-safe, after the provider e-signs the visit, we ensure that 100% of the codes are reviewed for completeness and accuracy by our team of AAPC CRC™ certified nurses, prior to submitting the codes to the health plan. We also deliver comprehensive provider ICD-10 coding and documentation training, which I personally provide and oversee.

What keeps you up at night in the current situation, with all the changes and disruptions in care during the pandemic?

PCP practices, particularly those who serve seniors, have endured some serious challenges. Reimbursement models are changing, and the new models demand vigilant documentation, accurate coding, additional practice resources, and subject matter expertise lacking by most physicians. At the same time, health plans are struggling to maximize risk adjusted revenue to ensure that seniors, who are the most vulnerable and costly patients, are receiving quality care and improved outcomes. Fortunately, CMS approved telehealth for a variety of encounters, including risk adjustment, and in-office patient volume has also started to bounce back from the post-pandemic decline. I think CMS will have to continue to adapt and make changes to the Medicare Advantage HCC model to account for the missed outpatient care during the pandemic. I am concerned about the increasing demands and worries of the PCPs, but I am optimistic about our ability to be a true partner, and subject matter expert, to help them succeed in this everchanging environment.

To learn more about how Vatica helps providers, watch our quick overview video.

The impact of telehealth on risk adjustment

In our recently published whitepaper, and in an article by our CEO, Hassan Rifaat, MD, published in FierceHealthcare, we discussed the current challenges health plans face to meet the requirements for risk adjustment during the COVID-19 pandemic. In the early innings of the coronavirus crisis, CMS implemented many helpful initiatives in response to the national emergency declaration, but none addressed risk adjustment. This created a lot of anxiety among health plans and other at-risk entities, given the importance of accurately risk adjusting your membership. Our hope, at the time, was that CMS would build on its series of telehealth waivers from March to allow health plans to gather risk adjustment data through telehealth visits.

Well, our dream has become a reality. Late last Friday, April 10, we all exhaled a collective sigh of relief when CMS officially approved telehealth as a means for health plans to gather risk adjustment data.

We applaud CMS for making this move, as it allows Medicare Advantage plans—which insure many of the oldest and sickest patients—to stay on track with risk adjustment. In addition, to the extent that the risk adjustment solution is provider-centric, it also enables primary care physicians (PCPs) to uphold care quality and address care gaps through preventive and routine care.

And while that’s good news for health plans, rolling out telehealth isn’t as simple as flipping a switch. PCPs and seniors may face obstacles in adopting and integrating what is a new technology for many of them.

During this period of transition, health plans should recognize the new challenges PCPs face and support them in continuing to provide care to their patients.


Challenge: Disjointed Telehealth Strategies

Telehealth usage is increasing but may be disjointed between audio and video methods and external telehealth solutions. In order to capitalize on the telehealth risk adjustment waiver, visits via telephone alone will not be enough. CMS has stated that PCPs can only gather encounter data for risk adjustment via real-time, interactive audio-video telecommunication systems.

Additionally, many outsourced telehealth solutions use clinicians with no relationship to patients or connectivity to a PCP’s EMR. While such solutions may be effective to treat acute needs when a patient’s PCP is unavailable, they should not be a substitute for a PCP-centric telehealth solution for risk adjustment and care coordination. Outsourced telehealth solutions will likely be ineffective and cause significant provider abrasion at a time when PCPs are struggling to keep their practices open.


Solution: Centralized, PCP-Centric Approaches

During this time, PCPs need solutions that keep them productive and engaged with their patients, rather than creating more work by picking up the pieces of an outsourced telehealth solution. PCPs also need support implementing this new care delivery model into their workflow.


Challenge: Strained and Under-staffed PCPs

As coronavirus care impacts all aspects of our business and personal lives, PCPs are under considerable stress, and their financial viability is being threatened. A survey of physicians in mid-April revealed that patient volumes are down 65% compared to pre-pandemic volumes, and the effects are beginning to catch up to the PCP practices. Shockingly, due to coronavirus effects, only one-third of PCPs feel confident that their practice has enough cash to continue operating through the end of April. Some practices have already decreased their workforce, and others think they’ll have to temporarily shutter their doors.


Solution: Member Engagement

Even though telehealth is now an option, practices still need help getting patients to participate. PCPs need easy-to-use member engagement tools with administrative and clinical support to secure patient participation. To optimize participation, health plans should promote PCP-centric telehealth to the members. Not only can this help maintain risk adjustment programs, but it also helps PCPs generate reimbursable revenue at a time when it’s needed most.


What’s Next?

While it’s hard to imagine that telehealth will ever fully replace in-person care, we expect that it will be our “new normal” for quite some time. This is especially true for seniors who are at the greatest risk of complications from COVID-19. We are cautiously optimistic that telehealth will remain in place for routine and preventive care and, if it does, we would expect CMS’ new guidance on risk adjustment via telehealth to also be extended. In the meantime, health plans should lean into PCP-centric telehealth programs to take full advantage of the new rules and flexibility relating to telehealth and risk adjustment during COVID-19.

Learn more about Vatica Health’s new PCP-centric telehealth and risk adjustment solution.