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Health plans participating in Medicare Advantage (MA) face multiple challenges: decreased revenue due to CMS-HCC V28, new Stars cut points and increased regulatory scrutiny, to name a few. In response to these headwinds, plans are withdrawing from markets, reducing benefits and increasing member out-of-pocket costs.

But less drastic options exist. In a recent webinar sponsored by the RISE Association, representatives from Vatica Health shared their experience working with health plans and providers across the country. Eric Wallace, senior vice president of provider sales, and Matt Neis, vice president of payer sales, discussed ways to maintain margin in this challenging environment.

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

Eye-opening results

A key factor affecting success in MA performance is risk adjustment. In Matt’s work with health plans, he finds MA organizations acknowledge they need to engage PCPs in risk adjustment coding and documentation. At the same time, they are aware of the difficulties with capturing the mindshare of PCPs, given all the demands on their time.

The playing field is changing, however, and value-based care is helping to drive that change. Eric shared a case study from a health plan that partnered on a risk adjustment solution with a $1.4 billion health system in the Northeast. This provider had “skin in the game” due to value-based care contracts. The organization understood the value of accurate coding and documentation, with 70% of their PCPs using the risk adjustment solution. The high provider engagement with a risk adjustment solution tailored for PCPs resulted in more accurate and complete risk adjustment coding. This engagement helped enhance patient care and contributed to a significant improvement in value-based care performance.

Matt and Eric shared how the health plan in the case study partnered with the provider and a third party—in this case, Vatica—to offer resources that help PCPs code and document accurately for risk adjustment. This includes both technology and dedicated clinical staff to review medical records and help PCPs identify and address applicable conditions. The program includes additional financial support from the health plan for participating PCPs.

The journey to success

Matt and Eric recommend that plans remove silos and improve communications among multiple departments to improve risk adjustment performance. The departments shown below should share responsibility for risk adjustment performance.

Another key is education about the purpose of risk adjustment. Most PCPs are not aware that accurate risk adjustment ensures appropriate resources for patients. Sharing this information builds trust among all parties. A neutral third party can assist with this education and provide resources that help build trust and foster collaboration between health plans and providers.

Vatica Health is the #1rated risk adjustment solution for health plans and providers. To learn how Vatica can bridge the gap between your organization and your provider network, visit vaticahealth.com.