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Health plans can adapt to the changing landscape of risk adjustment by equipping primary care providers with the right resources. This approach was highlighted by Vatica Health in collaboration with Paul Shields, MD, chief medical officer and chief executive officer of Great Lakes Integrated Network IPA (GLIN IPA).

Michael Rosenfeld, vice president for health plan sales at Vatica, described the current environment during a recent webinar for members of Health Plan Alliance. The new risk adjustment model coupled with increased regulatory scrutiny and changes to the CMS Stars program have created new challenges for health plans. In response, plans are asking providers to consider additional suspected conditions, improve documentation and close more care gaps. At the same time, primary care practices are facing their own set of challenges with inadequate staffing, transitioning to value-based care and reimbursement concerns.

A collaborative effort

Dr. Shields noted that providers often don’t see value in coding and documentation solutions provided by health plans. “Tech-only solutions” tend to waste PCPs’ time by surfacing conditions that have not been validated. Others provide lengthy reports and expect PCPs to upload that info into their EMRs. Plans can demonstrate their commitment to primary care by including providers in decision-making and supporting them with clinical and financial resources to complete the necessary work.

Michael stressed that a plan-agnostic, PCP-centric coding solution is best for meeting today’s stringent compliance regulations and actually improving patient care and outcomes. Vatica has found that including a “clinician in the loop” increases accuracy and provider engagement. Vatica’s team of nurses leverages proven technology to deliver more complete and reliable coding and documentation.

“CMS is moving from coding validation to clinical validation,” Michael noted. “Would a physician validate and support the coding and documentation provided?”

He shared this graphic highlighting Vatica’s process.

He added that clinical staff working with the advanced technology is the best method to drive accurate and compliant risk adjustment. Here’s why:

Service level is key

Dr. Shields noted that GLIN, with more than 900 providers, has found that using Vatica and its clinicians to review data increases accuracy, removes extraneous information and saves PCPs valuable time. He also noted that Vatica staff are always available for support, questions and ongoing education.

Dr. Shields called out recent solution enhancements based on provider feedback that resulted in fewer clicks and improved usability. As a result, the group’s time to complete reviews decreased from an average of 3.6 minutes to 1.9 minutes in just three years – even as the volume of visits increased from 18,800 to more than 32,000.

Michael and Dr. Shields concluded with these takeaways on risk adjustment solutions:

• The current market environment provides an opportunity to elevate primary care and the importance of PCPs being involved in risk adjustment initiatives to improve accuracy and patient outcomes
• Tech-only solutions for coding and documentation can be ineffective and cause PCP abrasion
• A solution that leverages both clinicians and intuitive technology produces better clinical and financial results
• A high level of service is essential for the best results
• Consistent support, actionable data and appropriate compensation drive provider engagement
• Recent RADV audit frequency and scope increases heighten the pressure of accuracy