Category: Value-Based Care

Improve compliance and financial performance with PCP-centric risk adjustment

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   

Four observations from the frontlines regarding our recent VBC survey 

By Whitney Chernoff, senior vice president for client engagement and growth operations, Vatica Health

Vatica Health recently conducted an independent survey of over 100 managers and executives of primary care practices and health systems to learn what’s working for them and what still needs to be addressed to facilitate a smooth transition to value-based care. 

As senior vice president for client engagement and growth operations at Vatica, I routinely meet with physicians and provider group leaders working through this transition. I would like to share some observations based on my experience working with those on the front lines of this exciting and challenging industry-wide transformation. 

1. Champions wanted 

While the survey revealed that the majority of respondents believe that VBC will lead to improved patient outcomes, many practices lag behind in implementation. The number one reason? Lack of staff. 

I can’t disagree with that; adding staff is certainly important. But a more important first step is finding a champion. Someone you can rely on to make sense of everything, keep up with changes and government regulations, identify the right initiatives to focus on, push your VBC initiatives forward, help you navigate around roadblocks, assess the financial impact and measure success. 

Ideally, this person should come from within your organization. Their knowledge of your people and processes will be invaluable when determining how best to navigate moving along the VBC continuum. Also, in today’s healthcare labor market, it can be difficult to find and hire outside experts. Once you find your champion, resources such as Vatica can provide them with expert support at no cost to your organization. 

2. The time is now 

CMS has a goal for 100% of Original Medicare beneficiaries to be in a care relationship with a VBC payment model by 2030. In addition, CMS recently announced the gradual transition to version 28 (V28) of the CMS-HCC model, which will be phased in and fully implemented by 2025. The changes from transitioning to the V28 model will make it more challenging to produce highly compliant revenue via risk adjustment. This could lead to a negative impact on your financial performance in the absence of a comprehensive, well-managed solution. While these new regulatory changes take hold, it is important for health plans to offer the right solutions to allow PCPs to continue or begin their transition to VBC. The sooner you begin, the sooner you can gain the advantages of VBC: improved patient care, reduced cost of care and better care coordination. 

3. Turnovers: bad for football, worse for your practice 

Caregiver turnover is a very real problem across the industry. And that’s especially the case with PCPs. Losing physicians means losing expertise and—potentially—patients. It can also mean losing continuity and creating greater strain for the PCPs who remain in place. Success in a VBC world means practices should do whatever they can to retain their most important and experienced staff. Like what? 

  • Implement strategies, policies or technologies that can improve everyone’s work-life balance. Carving out time for administrative tasks, which are often a necessary evil, can help ensure everyone works more efficiently and gets home at a reasonable hour. 
  • Explore ways to improve compensation models and incentive programs so more staff have a stake in the overall success of the organization. 
  • Provide pathways for continuing education. This not only engages employees; it also ensures your organization can grow and keep up with changes. 

By preventing brain drain, you reduce the cost of recruitment, onboarding and lost productivity and help ensure any VBC initiatives you implement will survive, evolve and thrive. 

4. Inertia is enemy #1 

One of the most common things I hear from providers is, “I’m too overwhelmed to think about how to not be overwhelmed.” But transitioning to VBC payment models can result in so many dividends for you and your patients; you HAVE to find the time. I understand how busy we all are. But if you can find a little time each week to meet with staff and outline a plan to move forward, you’ll find it gets easier—and more profitable. Consider outside resources to help. A vendor such as Vatica can reduce the administrative burden of coding and documentation for your providers while identifying open care gaps and ensuring accuracy and compliance. If you select the right resources, you can speed your time to adoption and get some time back in your day for yourself and everyone else at your practice.  

Read full survey here.

Partner with PCPs to maximize compliant risk adjustment yield

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

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

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.

Benefits of engaging PCPs in risk adjustment

As regulatory pressure mounts, health plans face challenges that impact the operations, compliance and results of their risk adjustment and quality programs. It’s become evident that PCPs should be at the center of risk adjustment efforts, but for payers and ACOs, that is easier said than done.

In a recent webinar hosted by Vatica Health for members of the RISE Association, Margaret Paroski, MD, CEO of Catholic Medical Partners, and Brian Flower, vice president of client solutions at Vatica, discussed this topic. You can view the webinar or read on for highlights of the presentation.

Dr. Paroski and Brian agreed that the risk adjustment landscape changed more in the past six months than the past six years. The Office of the Inspector General (OIG) has made clear its focus related to risk adjustment is on single submissions made by someone other than the patient’s care team. Under the RADV Final Rule, coding accuracy and specificity is even more important due to increased fines and penalties. The implementation of V28 under the 2024 Final Rate Notice introduced significant changes to the risk adjustment model including a reduction in the number of diagnosis codes that risk adjust and a shift in coefficient weight for many conditions.

The need to document all active conditions annually has remained constant. Dr. Paroski noted that, for most conditions, the PCP is the best source for that information. Often, the PCP has been caring for that patient for many years and has access to critical clinical data in the EHR. “We ask that you give us resources to help us, don’t try to replace us,” she advised payers.

Benefit #1: maximize compliant coding capture

Dr. Paroski offered several suggestions for payers to help providers code accurately and compliantly. Timely, patient-specific data presented within the provider’s clinical workflow is critical. In contrast, Dr. Paroski noted that surfacing low-probability suspected conditions overwhelms and frustrates providers.  In addition, provider education and training is very helpful.  Brian agreed, noting that highly focused and practical training, instead of broad and general education, is often more effective.

Benefit #2: improved outcomes

Supporting the patient/PCP relationship with enhanced payer collaboration empowers compliant code capture, improved utilization management, patient adherence and holistic care. This model enables more comprehensive and targeted data accuracy at the point of care with the opportunity for PCPs to close gaps in care by enabling a provider-centric model for value-based reimbursement activity. Payers can support this approach by offering PCPs a clear strategy and sponsored solutions to progress in value-based care (VBC) payment models.

Dr. Paroski suggests health plans find programs that work and build them into VBC contracts. Give providers data that goes beyond risk and HEDIS/Stars data. For example, information on patients’ social determinants of health is extremely helpful to PCPs. Equally helpful are community resources to address these issues, which many payers now offer but PCPs may not be aware of. Conversely, when payers auto-assign members that the PCP has no record of, this wastes the provider’s time and causes frustration. Likewise, when payers offer poor visibility into the provider’s VBC performance, it does not help improve outcomes. More collaboration, communication and transparency between payers and providers drives more accurate and compliant results.

Challenge #1: PCPs are busy

Dr. Paroski used the analogy of an online meal prep and delivery service to describe how payers can help busy PCPs. Blue Apron assembles, preps and premeasures the ingredients so the recipient just needs to follow the directions and cook the meal. Payers should do everything they can to make coding and documentation simple and efficient for PCPS. Allow providers to work at the top of their license, reimburse the staff for additional time, effort and expertise, and support providers with clinical and administrative resources. For maximum efficiency, don’t interrupt the PCP’s day or revenue cycle, interfere with time spent seeing patients, or overburden the clinical staff.

Challenge #2: PCPs do not feel valued

The healthcare system is asking PCPs to take on administrative responsibilities unrelated to why physicians chose the profession. Physicians did not go to medical school to become super-coders. Dr. Paroski noted that payers can help by paying fairly and quickly, and sponsoring programs that support physicians. In addition, payers should examine leveling the playing field for house-call visits so that PCPs get paid a fair amount for their time completing a house call. Given the OIG scrutiny on coding submissions from outside of the patient’s clinical care team, involving the PCP in a home or virtual visit designed to capture HCC codes is preferred. Brian noted home visits initiated by the PCP have a higher success rate in terms of acceptance by the patient and continuity of care.

“Stay in your lane,” Dr. Paroski added. “Don’t carve us out of care decisions or support risk adjustment programs that work around us. We can help fill the potential erosion of HCC RAF scores in the shift from V24 to V28 given our strong relationships with patients and access to all relevant clinical data.”

Dr. Paroski and Brian highlighted these key takeaways for the payers attending the webinar:

  • Provide timely, accurate and useful data
  • Provide viable VBC contracts and a clear path for evolution of VBC
  • Do the work you can do to support PCPs and don’t interrupt providers’ workflows
  • Pay providers fairly and quickly for the work they do

How Vatica Health can help 

Vatica Health is the #1 ranked PCP-centric risk adjustment and quality-of-care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge technology, Vatica increases patient engagement and wellness, improves coding accuracy and completeness, identifies and closes gaps in care, and enhances communication and collaboration between providers and health plans. The company’s unique solution helps providers, health plans and patients achieve better outcomes, together. With the Vatica team providing the extra resources needed for complete, compliant coding and documentation, physician participation is easier to enlist and sustain. To learn more, visit 

Understanding the financial impact of the RADV final rule

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

On January 30, 2023, the Centers for Medicare and Medicaid Services (CMS) released the final rule on Risk Adjustment Data Validation (Final Rule). The rule includes several changes. The most consequential is the new RADV audit methodology used by CMS to address overpayments to Medicare Advantage plans based on the submission of unsupported risk-adjusting diagnosis codes. The final rule authorizes CMS to extrapolate RADV audit findings beginning with payment year 2018 (not 2011-2017 as originally proposed). The industry views the use of extrapolation as especially punitive because in the Final Rule, CMS also rejected the application of the FFS Adjuster to account for an allowable threshold of errors related to provider medical record documentation. 

The financial implications of the Final Rule are significant. Prior to the Final Rule, repayment obligations were limited to errors found in a sample of a few hundred records. Under the Final Rule, that error would be applied across a broader population of the Medicare Advantage Organization’s contract. Recently, the Office of Inspector General (OIG) audited diagnosis codes submitted by a health plan for approximately 200 members. The OIG found a high percentage of codes were not supported in the medical record. This resulted in $480,000 in overpayments, though the health plan disputes the findings. The new extrapolation methodology would not apply in this instance because the alleged overpayments occurred in 2015 and 2016. If extrapolation did apply – instead of approximately $480,000 – the overpayments would result in an exponentially higher repayment amount of approximately $27 million.  

What can we tell about the extrapolation method if we consider these figures with membership data of the MAO contract in question? Straight-line math indicates that for each dollar of overpayment identified in the RADV sample, there’s an additional $55 of overpayment under extrapolation.   

We should be careful applying these assumptions to other populations, especially considering the highly targeted nature of this audit in question. The OIG targeted HCCs representing $695,000 in payments. Based on their review, 69% of those dollars could not be supported by documentation. However, what seems to be apparent is that an extrapolation methodology has been determined and, when applied, material payment modifications can result.  


The financial implications for RADV error rates will no longer be limited in materiality to small sample populations. Extrapolated penalties will be significant and potentially catastrophic to payers as well as at-risk providers. CMS estimates that from 2023 through 2032, the agency will recover an extra $4.7 billion from insurers via the new audit methodology. Given this, at-risk entities should evaluate their current risk adjustment programs and focus on solutions that produce accurate and compliant yield. Programs should include a robust quality improvement process to validate coding and documentation prior to submission. Legacy programs, such as retrospective chart reviews and in-home assessments, should be augmented with a provider-centric approach. Leading plans recognize PCPs as partners in coding accuracy and complete documentation to mitigate the risks associated with the Final Rule and the overall increased scrutiny on risk adjustment compliance. 

How Vatica Health can help 

Vatica Health is the #1 ranked provider-centric risk adjustment and quality of care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge technology, Vatica increases patient engagement and wellness, improves coding accuracy and completeness, identifies and facilitates the closure of care gaps, and enhances communication and collaboration between providers and health plans. The company’s unique solution helps providers, health plans and patients achieve better outcomes, together. Vatica Health is trusted by many of the leading health plans and thousands of providers nationwide. For more information, visit

Advancing health equity with an index

By Jamie Jenkins, PhD, MBA, CPHQ, quality of care director, Vatica Health

Advancing health equity is the first pillar of Centers of the Medicare and Medicaid Services’ (CMS) strategic plan. The Biden-Harris administration has committed to promoting racial equity through government programs focused on underserved communities. To that end, CMS’ 2023 Medicare Advantage Quality Rule released in April 2023 finalized the new Health Equity Index (HEI) for measuring how well Medicare Advantage and Part D plans manage at-risk populations.

What is the index?

The HEI will drive health plans to fully engage and take steps to address the social determinants of health (SDOH) which negatively impact health quality and outcomes.

CMS has defined HEI as an index or single score that encapsulates contract performance for plans whose enrollees face specific social risk factors. The index will use existing data to limit the number of members who are identified as vulnerable. Stratified plan members who receive a low-income subsidy, those with a disability and those who are dual eligible will be in the scoring pool. Health plans should begin analyzing their data and designing programs to support these members.

What are the goals?

The initial goal of HEI is to increase transparency and understanding of plan performance in addressing the needs of members facing social risks. First, the index will be used to identify populations with the greatest needs so that targeted assistance may be granted to communities and providers serving those communities.

Second, the HEI will allow beneficiaries to select plans based on performance on health equity measures. Third, the index would become part of the Star Ratings program which is used to incentivize health plans with bonuses to improve performance. Prior to this new approach, there were no targeted incentives to address disparities among a plan’s enrollees. The HEI would be an added layer encouraging investment in health equity initiatives for Part C and Part D Star Ratings.

Call to action

Health plans have time to begin examining their approaches. The baseline data for the initial calculation of the HEI will be based on calendar years 2024 and 2025. The performance reward will be included in the 2027 Star ratings year.

Health plans can start their data analysis by comparing contracts to one another. For example, plans may consider the variances between those populations receiving a low-income subsidy versus those who are not. Comparing groups will allow plans to determine where support is most needed.

Data collection is key

One of the five priorities outlined by CMS in the framework is expanding the collection and analysis of standardized reporting. The agency seeks comprehensive, interoperable and standardized individual-level demographic and SDOH data. With an increased understanding of members’ needs, CMS plans to leverage quality improvement and other tools to ensure all members have access to equitable care and coverage.  

CMS notes that developments in health information technology have improved the ability to collect health data and measure disparities at the provider level. Vatica Health, for example, provides technology and dedicated clinicians to enable providers to efficiently capture more accurate and complete diagnostic coding and documentation both for risk adjustment and improving quality of care. Vatica’s team of nurses curates relevant clinical data from various sources and creates a pre-encounter provider notification to enable more comprehensive encounters. The notification lists medical conditions, unreconciled medications and targeted quality measures to help the provider efficiently address the patient’s needs during the visit. As part of this process, Vatica can collect race and ethnicity information as well, using CDC specifications.

In summary, this framework is the first step in CMS’ drive toward improving health equity. “Our goals for Medicare Advantage mirror our vision for CMS’ programs as a whole, which is to advance health equity; drive comprehensive, person-centered care; and promote affordability and the sustainability of the Medicare program,” said CMS Administrator Chiquita Brooks-LaSure.

How Vatica Health can help

If you are considering a partner to help improve your Star quality measure performance, consider Vatica Health. We are the #1 rated risk adjustment and quality of care solution for health plans and health systems. By pairing expert clinical teams with cutting edge technology, Vatica increases patient engagement and wellness, improves coding accuracy and completeness, identifies and facilitates the closure of care gaps and enhances communication and collaboration between providers and health plans. The company’s unique solution helps providers, health plans and patients achieve better outcomes together.

How complete and timely data exchange can improve VBC outcomes

Doctor typing on a laptop

As an old saying goes, “timing is everything.” In value-based care (VBC), that’s especially true—particularly when it comes to data exchange. Timely data exchange is essential. It provides greater visibility into a patient’s overall health during a face-to-face encounter, enabling providers and payers to deliver the best care with the appropriate resources.  

There’s no question that VBC thrives on accurate and timely data. Data identifies target patient populations. It spots risk factors and care gaps. It can highlight problem areas and drive appropriate interventions. And when leveraged effectively, it improves efficiency, measures progress and ultimately enhances VBC performance.  At the end of the day, having a 360-degree view of current patient information is essential to making sense of a patient’s health and making the best care decisions at every encounter.

Despite the importance of leveraging actionable data at the point of care, there are some formidable stumbling blocks. Relevant clinical data is often siloed – stored in different systems that do not communicate with each other. Payers, providers and pharmacies maintain separate databases that are not reconciled. This can lead to conflicting information, confusion and ultimately, subpar care. 

There has been a lot of progress to enhance integration and interoperability among various EMRs, stakeholders and systems — but we are still in the early innings. A lot of healthcare data is contained in unstructured formats or trapped in an EMR that doesn’t integrate with other databases. A readily available single source of truth with all relevant clinical information to inform a patient encounter and real-time decision making is rare. Therefore, providers and payers unknowingly make decisions based on incomplete and conflicting information. This impacts care and outcomes and leads to the inefficient use of resources.    

While current and timely data exchange is critical, it’s not a panacea. There has been a lot of progress in healthcare technology, such as artificial intelligence and natural language processing, but nothing replaces the judgment and experience of a trained clinician. A lot of important patient information remains trapped in unstructured formats such as images and physicians’ notes, which technology alone doesn’t sufficiently address. In addition, complex algorithms are rendered useless if the underlying clinical data is inaccurate.

The holy grail is to arm specially trained clinicians with powerful tools to curate all relevant patient information at the time of the encounter and leverage technology to supercharge, not replace, physicians. The combination of the right data, the right clinical resources, at the right time would help drive the most efficient and informed patient visits, lower costs, enhance care and drive practice performance in VBC and other risk sharing arrangements.

How Vatica can help

Vatica Health offers a unique model that pairs expert clinical teams with cutting edge technology at the point of care.  This innovative combination produces a powerful biproduct – sensemaking machines that help our clients wade through a sea of data to garner insights and make better clinical decisions. 

 Vatica’s licensed nurses curate all relevant clinical data to inform comprehensive visits. This information is conveniently documented and provided to the PCP prior to the visit. Only vetted HCC codes and care gaps are presented so PCPs can make the most of their time with patients. Health plans purchase the Vatica solution and make it available to PCPs in their network at no cost to help improve coding and documentation for risk adjustment. A key component of VBC, risk adjustment ensures that risk bearing entities are properly compensated and that adequate resources are available to care for patients, based on their specific conditions and healthcare needs.

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

By Lindsay Dosen, senior vice president of legal and compliance, Vatica Health

As more physician groups move into value-based care (VBC), many are encountering risk adjustment compliance issues they aren’t prepared for. Some of these issues can have serious legal and financial consequences if left unchecked. Preparing for these issues will enable physician practices to successfully transition to, and thrive in, a VBC environment by reducing compliance risk, improving patient outcomes and boosting financial performance. This article focuses on three common VBC compliance risks that PCPs should be aware of—along with recommendations on how best to mitigate them.

Risk 1: Unsubstantiated HCC codes

With the traditional fee-for-service payment models that PCPs have historically operated under, health plans—not PCPs—have primarily focused on accurately capturing Hierarchical Condition Category (HCC) codes for purposes of risk adjustment. However, under VBC arrangements (depending on the type of gain-sharing relationship), PCPs must focus on accurately capturing and documenting HCC codes. Underreporting or missing codes could translate to lost revenue for the PCP. Overreporting or submitting HCC codes that are inaccurate or unsubstantiated could subject the PCP to legal liability and regulatory penalties.

While this has been a major issue for health plans in recent years, this is also becoming a significant compliance risk for PCPs, as regulatory agencies have increased scrutiny of the risk adjustment programs and activities of both health plans and healthcare providers. These regulatory actions often assert violations of the False Claims Act (FCA) based on the government’s position that the risk adjustment payments were artificially inflated due to inaccurate or unsubstantiated diagnoses codes. Violations of the FCA can result in multi-million-dollar fines, not to mention lasting damage to a physician group’s public image and reputation, even when the violations were committed in error and without intentional wrongdoing by the PCP.

Fortunately, there are ways PCPs can protect against this compliance risk. First, PCPs should avoid payment structures that base payment on either a higher number of codes or higher-value codes. These types of payment arrangements are construed by the Department of Justice (DOJ) as problematic because they incentivize over coding and upcoding. Second, PCPs should provide training that reinforces the importance of compliant and accurate coding and that educates their staff about the potential legal, regulatory and financial risks associated with submitting inaccurate or unsubstantiated codes. Last, PCPs should invest in compliance programs that review coding and documentation to ensure accuracy.

Risk 2: Improper medical record review and sign-off

Another common VBC compliance issue that PCPs face is medical record compliance. You would think that the Centers for Medicare and Medicaid Services (CMS) recommended medical record review and sign-off process would be simple and straightforward. And it is—but only if the right person is doing it.

CMS outlines specific requirements as it relates to medical record documentation and risk adjustment diagnosis codes. Submissions with documentation issues could impact the validity of the medical record in a Risk Adjustment Data Validation (RADV) audit, leading to a potential discrepancy for the audited CMS-HCC findings. For a diagnosis to be risk adjustment-eligible, it must result from a face-to-face encounter with an approved provider type. The medical record must have, among other things, a valid signature and credentials for the approved provider. For PCPs, that means not just anyone in the practice can sign off on a medical record. A CMS risk adjustment-approved physician must be present during the face-to-face encounter. The record must also be signed by the CMS risk adjustment-approved provider. Learn more here.

This is an issue that can be easily remedied with proper education and training. PCPs should take steps to make sure that their staff clearly understands the importance of following the CMS guidance related to medical record documentation for risk adjustment. PCPs and their teams should read and be familiar with these compliance guidelines and should develop and implement policies and procedures to ensure compliance.

Risk 3: Vendor non-compliance

A third VBC issue is the misconception that a PCP’s responsibility for compliance is limited to only activities within the practice. If a PCP is working with an outside vendor that is non-compliant, the PCP may also be held liable for the vendor’s compliance violations.

The best way to mitigate this risk is to vet prospective vendors thoroughly in advance to ensure they have a clean compliance record and a strong compliance program in place. When selecting a risk adjustment vendor, PCPs should conduct due diligence to include, without limitation, reviewing information about the vendor’s compliance and security programs, any applicable coding policies and procedures, mechanisms for reporting suspected fraud, waste and abuse, exclusion screening, and any prior enforcement or legal actions taken against the vendor. In addition, a thorough review should be completed of the vendor’s operations related to the services being provided, including coding. Finally, PCPs should be thoughtful when structuring any fee arrangements with the vendor so as not to encourage over coding or upcoding. Payments under the arrangement should be based on the scope and quality of the services performed, without fluctuation (including bonuses or penalties) tied to the value or volume of the diagnosis codes captured.  

Final recommendation: appoint a compliance lead

These three issues are examples of the compliance risks that PCPs operating in VBC are faced with every day. However, they are also examples of how an effective compliance program can help PCPs successfully navigate these issues and substantially reduce risk in VBC arrangements. An important way to ensure the PCP has an effective compliance program is to appoint a compliance lead for the practice. The compliance lead should stay up to date on compliance requirements and guidelines, develop policies and procedures to ensure compliance, provide training, promote awareness, and monitor and enforce compliance within the organization. An effective compliance program, led by a person with knowledge and expertise related to the compliance risks and regulatory requirements that are applicable to VBC, can greatly mitigate the compliance and financial risks to the practice. With compliance adequately addressed, PCPs can focus on delivering efficient, high-quality care to patients, which leads to successful financial performance in a VBC arrangement.

Celebrating Healthcare Quality Week: Meet our quality team

Vatica is celebrating Healthcare Quality Week by spotlighting our talented and caring clinical quality team. This team collaborates with providers to improve care and close care gaps, which enables our health plan clients to consistently achieve high star quality ratings from CMS. Their dedication to proper coding and documentation helps ensure our clients’ Medicare Advantage members receive the care they need.

Meet the team:

Dr. Averel Snyder, Chief Medical Officer and Co-Founder

Meet Dr. Averel Snyder, Vatica’s chief medical officer and co-founder. Dr. Snyder is a cardiothoracic surgeon, practicing for over 25 years. He understands how software could enhance both the patient and provider experience in connection with a top-notch clinical quality team, which he helped create here at Vatica.

Elaina Greer, Senior Director of Quality Programs

Meet Elaina Greer, Vatica’s senior director of quality programs. Elaina understands the importance of standardized measurement and how it can provide insight to improve quality of care. She would love to see the U.S. achieve health equity in healthcare in her lifetime. “It is the single most impactful step we can take to achieve our aim of improved patient outcomes and affordable, quality healthcare,” she explains.

Jamie Jenkins, Quality of Care Director

Meet Jamie Jenkins, Vatica’s quality of care director. Jamie works in quality because it’s an essential way to directly improve population health. Some of Jamie’s accomplishments in the field include implementing the first chronic care clinic for the University of Louisville physicians and leading a quality diabetic program that improved quality scores from 15% to 65%.

Kimberley Jacobs, Senior Clinical Compliance Specialist

Meet Kimberley Jacobs, Vatica’s senior clinical compliance specialist. Kimberley’s entire career has focused on quality in healthcare. Working 15 years of her career as a physician assistant, Kimberly has experience with quality that focuses on patient care. She uses that knowledge to support Vatica’s technology in improving patient care.

Danielle Layton, Clinical Quality Assurance Auditor

Meet Danielle Layton, Vatica’s clinical quality assurance auditor. Danielle has 20 years of clinical experience working as a certified physician assistant. She is certified in inpatient, outpatient, and risk adjustment medical coding and has been distinguished by the US Department of the Army for taking care of injured soldiers returning from Iraq and Afghanistan.

Bli Franklin, Senior Quality Analyst

Meet Bli Franklin, Vatica’s senior quality analyst. Bli knows data and its importance on population health. She is a certified professional coder and serves as a committee member for The Gravity Project, a national collective charged with building the data standards for social determinants of health.

Lauren Zoback, Senior Director of Quality Improvement

Meet Lauren Zoback, Vatica’s senior director of quality improvement. Lauren has been with Vatica for more than five years. She is a registered nurse and perfectionist by nature. Her keen eye for detail plays an important role in her work in healthcare quality, analyzing, and solutioning.