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Historically, many health plans viewed prospective risk adjustment programs as nice to have but challenging to implement. Part of the challenge comes from the necessity to involve busy PCPs in a prospective solution. But the CMS 2027 Advance Notice forces health plans to consider this model.

In the past 10 years, CMS has steadily increased oversight of risk adjustment. Expansion of RADV audits and extrapolation, Department of Justice enforcement actions under the False Claims Act and implementation of CMS-HCC V28 all demonstrate this trajectory.

Additionally, the structural weaknesses of legacy retrospective models and in-home assessments have come to the forefront. These models exclude the PCP, have limited clinical impact, increase audit exposure and do not enhance member experience. Backward-looking retrospective programs limit effectiveness of code capture. A program consisting only of retrospective chart reviews is myopic and does not support the outcomes-driven, population health management focus inherent in most payment models today.

Thus, the CMS 2027 Advance Notice proposes to significantly curtail the use of in-home assessment and other retrospective risk adjustment diagnoses that are not supported by a qualifying patient encounter.

Prospective solutions take center stage

Prospective risk adjustment programs permit timely, effective interventions. This includes presentation of suspected gaps in care and the opportunity to achieve thorough and accurate documentation, which supports coding to the highest degree of specificity.

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

PCP engagement is the key to success. Involving PCPs improves care delivery and facilitates care gap closure by leveraging a proactive approach providing timely clinical and administrative support, education and performance management.

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

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

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

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

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

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

Vatica recently merged with Cozeva, another industry leader in risk adjustment and quality solutions. The combined organization offers a comprehensive suite of solutions to meet the unique needs of health plans and providers. This includes tech-only solutions, a payer-agnostic model and a track record of helping plans maintain yield without sacrificing compliance.

Complying with the proposed CMS regulations will be more than just a vendor switch for health plans. It will require transformation of operating models. But choosing the right partner is critical. A prospective solution that offers flexibility, provider engagement and the ability to maintain compliant yield is critical.