Tag: coding

What’s behind the move from retrospective to prospective risk adjustment?

By Vatica Health | July 10, 2024 | Provider, Risk Adjustment

Health plans across the country are recognizing the superior value of prospective risk adjustment programs, and rightfully so. These programs have impact at the point of care, as opposed to retrospective programs which are essentially chart reviews. 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.

Conversely, backward-looking retrospective risk adjustment programs limit effectiveness of code capture. A risk adjustment 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.

Which one is the optimal approach to risk adjustment? The answer: an effective mix of both. But most important is primary care physician (PCP) engagement. A winning risk adjustment strategy is heavily weighted towards prospective interventions but may need to include some retrospective elements to meet PCPs’ needs.

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 forecasting the cost of care for your Medicare Advantage, Medicaid and commercial lines of business.

PCP engagement is the key to success across all risk adjustment strategies, especially prospective programs. PCP engagement improves care delivery and closes gaps in care 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 physicians would collaborate to reduce costs and improve health, quality and outcomes. Additionally, members 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. Physician engagement requires timely, ongoing support. It is essential to augment practices with dedicated clinical resources who curate information to save the physician 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 physician engagement are critical. Successful programs supply expertly trained people, easy-to-use technology, turnkey processes and aligned financial incentives to achieve and maintain physician engagement.

Lastly, member engagement is an important piece of the puzzle. Physicians are more likely to engage in programs that drive material clinical improvements for their patients, 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 physician-centric approach to risk adjustment and clinical quality. We pair expert clinical teams with cutting-edge technology to work with physicians at the point of care. Vatica Health 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 deleted prior to submission of the Vatica record to the health plan sponsor.

Advantages of partnering with Vatica Health

Our licensed registered nurses and administrative staff are dedicated to providing the best experience for PCPs and their office staff. Our attention to documentation and coding validation through Vatica’s quality improvement process improves accuracy and reduces compliance risk. Vatica’s clinical and administrative staff work closely with each practice to develop a custom workflow and process, achieving an ideal state that yields the best results with the least amount of effort for PCPs.

When health plans partner with Vatica Health, they ensure a comprehensive, collaborative and prospective risk adjustment program that’s a win-win for everyone, including patients. To learn more, visit vaticahealth.com.

Another blow to detached health risk assessments

By Vatica Health | June 4, 2024 | Provider, Risk Adjustment, Value-Based Care

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

Health Affairs recently published a study of data from 4 million Medicare Advantage (MA) members indicating that health risk assessments (HRAs) contributed up to $12 billion per year to risk adjusted payments in 2020. This is based on conditions that were submitted exclusively by an HRA (not submitted through another encounter) during the 2019 calendar year. The study implies that HRAs, typically performed in-home by vendors on behalf of MA plans, can lead to inflated hierarchical condition category (HCC) scores. More specifically, of the 44.4% of MA beneficiaries who had an HRA, HCC scores increased on average 12.8%.   

Study authors go a step further by segmenting contracts as low, medium and high, based on the HRA’s effect on risk score at the contract level. This may provide insights into HRA program design by the plan, e.g., which patients are targeted and how HRA outcomes are subsequently attached to care management.   

For nearly a decade, the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG) have expressed concern with the improper use of HRAs to inflate payments, rather than to improve care and outcomes. While HRAs can be a helpful tool for plans to identify all active conditions on an annual basis, the disconnect or “detachment” arises when diagnoses captured in HRAs are not recorded in a subsequent medical visit. This undermines the purpose of risk adjustment, which is designed to compensate plans based on the expected costs of delivering benefits to enrollees.    

Key observations 

  • The population was designated as follows: 20% low, 15% high and the remaining 64% in the medium cohort. 
  • While comprising only 15% of enrollees, the high cohort accounts for 48% of the total HRA risk-score increase. 
  • The HRA rate was much higher in the high contracts (77.9%) than low contracts (39.5%). 
  • Quality ratings favored low cohort contracts with 85% 4 stars or better vs high cohort contracts at 56%.  
  • Provider and health system integration was dramatically higher in the low vs the high contract cohort.   
  • Comparing the high and low contract cohorts, while the overall HCC score was 18% higher, medical expense was 9% lower (estimating from the plan payment and medical loss ratio values provided). 

Extrapolating on the points above, PCP-integrated risk adjustment solutions drastically reduce the risk of detached HRA outcomes and quality performance. This stands to reason because the patient’s PCP is prioritizing healthcare outcomes and management of chronic conditions, rather than focusing exclusively on code capture.     

The correlation between HRAs and coding intensity is particularly relevant given the Risk Adjustment Data Validation (RADV) Final Rule, which authorizes CMS to extrapolate RADV audit findings beginning with payment year 2018, applying the error rate from a sample, and the associated financial penalties, across a broader population of the Medicare Advantage Organization’s contract. In a RADV audit, conditions supported by a single encounter, like detached HRA visits, are at higher risk because there are no additional medical records to fall back on if there is an access, accuracy, or completeness issue with the primary record.  A PCP-integrated approach encourages follow-up care and additional documentation to support valid diagnoses.   

It should be noted that this study uses the 2020 CMS risk adjustment model.  We expect the exclusive impact of HRAs on risk scores would be tempered by as much as 40% using the 2024 risk adjustment model, which is being phased in now and will take full effect for 2025 dates of service. 

Conclusion  

At-risk entities should evaluate their current risk adjustment programs and focus on solutions that produce accurate and compliant coding accuracy that dovetail with quality and health outcomes. Legacy programs, such as retrospective chart reviews and HRAs completed by in-home assessment vendors, should be augmented with a provider-centric approach. Build a risk adjustment strategy that recognizes PCPs as partners in accuracy and quality capture, as well. PCPs are best positioned to capture all existing conditions and to address the CMS and OIG’s concerns by connecting the dots between accurate HCC capture and improved care and outcomes. 

A wave of CMS regulatory changes – a new paradigm for risk adjustment

By Vatica Health | April 10, 2023 | Compliance, Risk Adjustment

By Steve Zuckerman, cofounder and chief strategy officer, Vatica Health

Over the last several months there have been dramatic regulatory changes that will have a significant impact on Medicare Advantage Organizations (MAOs). The Centers for Medicare and Medicaid Services (CMS) made sweeping changes to both the audit process and underlying risk adjustment model, based on concerns with coding of conditions that the government claims are not credible predictors of future expenditures. These changes are against the backdrop of a wave of lawsuits and reports by the Office of Inspector General (OIG), alleging billions in overpayments emanating from legacy risk adjustment models such as chart reviews and home assessments.

Risk adjustment is the foundation of Medicare Advantage (MA). It’s a necessary but complicated process that ensures at-risk entities have sufficient funding to provide the appropriate care and resources to members based on their clinical profiles. As membership in MAOs has steadily increased over the last decade, so have the costs, leading to recent reforms. The first blow occurred on January 30, 2023, when CMS released the final rule on Risk Adjustment Data Validation (RADV Final Rule). This rule authorizes CMS to extrapolate RADV audit findings across a health plan’s entire membership base. The practical effect is that audits will be more frequent, and the new extrapolation methodology will likely result in much more significant fines and penalties (CMS estimates it will collect $4.7 billion more from plans over the next 10 years).  

The government’s next initiative to address coding errors and variations occurred on March 31, 2023, when CMS released the Calendar Year 2024 MA Capitation Rates and Part C and Part D Payment Policies (Final Rate Notice), which shifts diagnosis coding from ICD-9 to ICD-10 and removes over 2,000 codes from the Hierarchical Condition Categories (HCC) model. Despite a massive industry-wide lobbying effort from both payers and providers, the new risk adjustment model was adopted. However, CMS did agree to a phased-in approach over three years which represents a meaningful concession.

Finally, on March 27, 2023, a bipartisan senate bill was introduced by Sens. Bill Cassidy, R-Louisiana, and Jeff Merkley, D-Oregon, entitled the “No Unreasonable Payments, Coding or Diagnoses for the Elderly Act.” This bill seeks to exclude diagnoses from chart reviews and health risk assessments in the calculations of a patient’s risk score. While the bill is in the early stages of consideration, it is consistent with the prevailing perspective and momentum away from legacy models and toward involving treating providers in the risk adjustment process.

The phased-in approach under the Final Rate Notice gives MAOs an important opportunity to review their risk adjustment solutions to make sure they will be effective under the new regulatory landscape. Here are a few practical strategies to consider:

  1. Provider-centricity will be more critical than ever. As we transition to value-based care, it is critical for payers and primary care physicians (PCPs) to work together to improve care, outcomes and costs. Accurate risk adjustment is essential to ensure appropriate care for MA patients, the fastest growing healthcare segment. Therefore, it stands to reason that payers and providers should collaborate on risk adjustment and quality initiatives. Further, given the loss of several valuable HCCs under the Final Rate Notice, it will be more important than ever to ensure the capture and clinical substantiation of all risk adjustable conditions. Legacy models are deficient, work around providers, disrupt continuity of care and don’t accompany patient care plans. A better approach is to empower the PCP with tools and resources to perform HCC coding because the PCP has an existing relationship with the patient, direct knowledge of the patient’s history, and real-time access to the patient’s medical records. Enhanced payer and provider collaboration in this regard can produce better clinical and financial performance.

  2. Reevaluate chart reviews and home assessments. Chart reviews and home assessments that lack connectivity to the PCP and don’t impact care are being targeted by the Department of Justice, CMS and OIG. Both may become obsolete if the “No Upcode Bill” is ultimately passed. Lack of clinical oversight and perverse incentives within these legacy risk adjustment models create an environment ripe for error and malfeasance. Another major concern is that they are not coordinated with treating providers and therefore have minimal impact on improving overall population health and value-based care performance. Consider ways to coordinate your chart review and home assessment programs with in-office solutions to keep PCPs at the center of care.

  3. Focus on accuracy. In light of the RADV Final Rule and the myriad of lawsuits and investigations, at-risk entities should invest in solutions that produce compliant yield. They should focus on improving accuracy and completeness of documentation and coding and include a QI process that reviews both additions and deletions to validate coding prior to submission. The shift to value-based care will put even more pressure on payers and providers to use compliance-centric solutions that are focused on improving the accuracy and completeness of diagnoses codes and documentation.

How Vatica Health can help

Vatica Health is 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 provider-centric solution is used prospectively at the point of care, giving the provider control and ensuring continuity of care. The 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 vaticahealth.com.

The RADV final rule – strategies for mitigating the impact

By Vatica Health | March 13, 2023 | Compliance, Risk Adjustment

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

The Centers for Medicare and Medicaid Services (CMS) released on January 30 the long-awaited final rule on Risk Adjustment Data Validation (RADV). The rule includes two significant modifications to the RADV audit methodology used by CMS to address overpayments to Medicare Advantage plans based on the submission of unsupported risk-adjusting diagnosis codes. First, the final rule authorizes CMS to extrapolate RADV audit findings beginning with payment year 2018 (not 2011-2017 as originally proposed) but did not elaborate on the extrapolation methodology. Second, a fee-for-service (FFS) adjuster will not be applied to RADV audit results, which was previously leveraged as a method of normalizing Medicare Part C payment errors against fee-for-service Medicare.

Industry leaders and health plan advocates have expressed concerns. Matt Eyles, president and CEO of America’s Health Insurance Plans, said, “Our view remains unchanged: this rule is unlawful and fatally flawed, and it should have been withdrawn instead of finalized. The rule will hurt seniors, reduce benefits for those who choose MA, and yield fewer plan options in the future.”

Health plans had similar reactions. “While we all can agree that improvements can be made, the failure to adjust for the legitimate differences between Medicare Advantage and original Medicare will have a detrimental effect on the seniors and people with disabilities who rely on the Medicare Advantage program,” the BCBS Association said. “CMS should have implemented a narrower solution aimed at a few bad actors, but instead this overreaching regulation will raise costs, reduce choice and make it more difficult for seniors and those with disabilities to effectively manage their health.”

As analysis of the rule continues, here are a few insights and practical strategies we have shared with our payer and provider clients.

  1. Assess your “thin HCC” risk
    Even while the focus remains on accurate submissions, some HCCs will be easier to substantiate than others in an audit. It is important to understand what percentage of your submissions and Risk Adjustment Factor share would qualify as “thin” (associated with only one or two encounters, especially if significant effort is required to obtain a valid medical record). Understanding your risk will inform decision making on remediation within and after a given measurement period, as well as financial planning. 
  2. Prioritize treating providers
    Invest in programs that inform treating providers and empower them to code directly and accurately in a consistent and submittable manner, in favor of downstream coder abstraction that is not associated with the patient’s care plan. Engaged providers will become better organic coders over time, and a structured process can ensure necessary supporting documentation is reliably collected. In addition, compliant conditions collected shortly after encounters are recognized earlier than retrospective coding, allowing plans to identify open revalidation candidates within, instead of after, the measurement period.
  3. Anchor on primary care
    The clinical benefits of encouraging a strong patient-to-PCP relationship are largely understood. Build a risk adjustment strategy that recognizes PCPs as partners in accuracy and quality capture as well. PCPs are your starting lineup for long-term chronic care management, medication compliance, specialty referrals and testing needed to fully assess many HCCs.
  4. Engage the member
    As scrutiny over coding escalates, payers and providers should collaborate on member engagement to ensure annual visits are performed so that chronic conditions can be properly managed, as well as documented. Medicare Annual Wellness Visits (AWVs) are a great opportunity to engage patients in preventive care. AWVs can also be used as a springboard to participate in health plan-sponsored programs designed to capture accurate clinical documentation and close risk and quality care gaps. This expanded scope, which Vatica Health has dubbed an “Enhanced Wellness Visit,” ensures appropriate care and reimbursement while enhancing performance under value-based care arrangements.
  5. Focus on accuracy above all else
    The final rule can result in more severe penalties, as well as myriad legal actions against payers and providers relating to alleged improper practices focused on boosting risk scores and associated payments. In light of this, at-risk entities should evaluate the compliance (real and perceived) of their current risk adjustment solutions. Consider solutions that produce compliant yield, focus on improving accuracy and completeness of documentation and coding, and include a QI process to validate coding prior to submission.

How Vatica Health can help

Vatica Health is the leading 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 https://www.vaticahealth.com/.

Elevating risk adjustment by activating physician participation

By Vatica Health | March 3, 2023 | Risk Adjustment

As the pandemic subsides, many PCP groups are seeking to restart or ramp up value-based care (VBC) initiatives that took a back seat to battling COVID for the past two years. The economic impact of COVID on PCPs heavily reliant on fee for service and the looming recession will only accelerate the transition to VBC. However, it does come at a time when many providers are short-staffed and feeling overwhelmed.

A recently-released three-year study by JAMA revealed that, between the fall of 2019 and early 2022, the percentage of healthcare workers who perceived emotional exhaustion in their workplace climate increased from 53.3% to 64.9%. The unfortunate reality is that many physicians are struggling with burnout which has been greatly exacerbated by the multi-year COVID crisis. Addressing this challenge requires collaboration and coordination of efforts among payers and providers.

How can care providers and payers work together to activate physician participation in this climate to improve diagnosis coding and documentation, close gaps in care, achieve better clinical and financial performance, and support VBC initiatives? Some answers were offered in a “Bright Spots in Healthcare” podcast.

Moderated by host Eric Glazer, the podcast offered the perspectives of a diverse, blue-ribbon panel of experts:

  • Jeslie Jacob, divisional vice president, provider analytics, reporting and connectivity, Blue Cross and Blue Shield of Illinois
  • Janie Reddy, DNP, FNP-BC, director of family medicine, CommuniCare Health Centers
  • Rebecca Welling, associate vice president, risk adjustment and coding, SelectHealth
  • Lisa Wigfield, RN, BSN, CCM, CRC, CDEO, clinical advisor, risk management, Priority Health
  • Hassan Rifaat, MD, CEO of Vatica Health

Watch the whole podcast to get the full story, but in the meantime, here are some key pieces of advice from the panel:

“The key is to bring the gaps in patient care into the workflow at the point of care.”

Successful VBC is built on data and analytics, but as Jeslie Jacob stressed, gaps in care must be visible at the clinician’s fingertips when interacting with the patient. Jacob emphasized the value of EMR integration and dashboards to ensure that clinicians have ready access to up-to-the-minute insights when they meet with patients.

“Capture as much as you can during the visit.”

Janie Reddy emphasized maximizing the opportunities presented by the office visit. “If a patient comes in for an acute visit – say, for a cough – we treat the cough, but we’re also looking to see if they’ve had their preventive screenings,” she said. “If they’re diabetic, have they had their A1Cs done for the year? We’re looking at the whole picture: all their quality metrics. It’s all embedded in data analytics and presented via dashboards that show us exactly what is outstanding for each patient.”

“It’s got to be documented to capture it.”

Data goes both ways, according to Lisa Wigfield. You’re not just using historical health data to inform the office visit; you’re also generating new, vital data during the visit. For that reason, she cited the importance of documenting everything, thoroughly and accurately. Wigfield mentioned how Priority has enhanced MA benefits and offers a “free to talk” visit that has no copay. The visit provides an opportunity for PCP and patient to talk about health. It’s a good way to address care gaps and discover new issues the PCP may not be aware of.

“Go from a physician-only approach to a team approach.”

Reddy is a firm believer in sharing the VBC workload among physicians and other staff so that the burden doesn’t fall disproportionately on physicians. There are several advantages to this. For one thing, it enables physicians to accomplish more during the time they have with patients. Secondly, it builds a sense of VBC ownership across the entire team. When everyone feels that they are being supported by their colleagues in making VBC work, the effort will be more sustainable. However, keep in mind that a successful team approach requires that each team member has a clear understanding of their role and responsibilities and the practice’s expectations of them.

“Make sure health plan incentive dollars flow down to the practice.”

Incentive dollars aren’t much of an incentive if the people earning them don’t receive them. That’s why Hassan Rifaat, MD, stressed that clinicians should be paid directly for the work they’re doing. He urges practices to “make sure money is flowing down into the practice, from providers to support staff; invest the time to figure out how to do that.” That tangible ROI for the team’s VBC efforts will help ensure their continued commitment. Dr. Rifaat also made a key point about the economics of VBC implementation: “The upfront costs of a VBC program are significant and it can take as long as two years for some of those investments to start generating positive cash flow,” he said. “Once it does, it’s self-funding. But until that happens, some form of subsidy can help providers make the investments needed to get their VBC program off the ground.”

“Be sure to include staff in the incentives.”

When it comes time to share incentives with staff members, PCPs have any number of ways to do it. Which is best? Rebecca Welling believes one effective way is to link specific incentive payments to the successful performance of specific tasks. “For example,” said Rebecca, “you could offer to pay your scheduling staff $25 for every one of these high-acuity patients they bring in.” The direct connection between task and reward can be a strong incentive.

“Take advantage of friendly competition.”

Don’t be reluctant to share provider performance data within your organization to spur friendly competition. Reddy said, “As clinicians, we have a competitive drive within ourselves, and this has really motivated us to push each other to deliver quality care to our patients.” Bottom line? Money isn’t the only incentive; competition can be a powerful tool, as well. To encourage competition, Dr. Reddy said “Dashboards are our friend.” Readily accessible and easy-to-read dashboards make it simple for physicians to compare their work with their peers’.

How Vatica Health can help

The Vatica Health solution directly supports many of the recommendations made by the experts on the podcast. Vatica Health is the leading PCP-centric risk adjustment and quality-of-care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge, 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 to get VBC off the ground and operating successfully, physician participation is easier to enlist and sustain. To learn more, visit https://vaticahealth.com/.

How complete and timely data exchange can improve VBC outcomes

By Vatica Health | December 13, 2022 | Value-Based Care

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 Vatica Health | December 1, 2022 | Compliance, Risk Adjustment, Value-Based Care

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.

Why a “technology-only” approach will not drive value-based care performance

By Vatica Health | February 16, 2022 | Provider, Risk Adjustment, Value-Based Care

Over the last few years, we’ve witnessed significant advancements in medical technology including the proliferation of telehealth, remote patient monitoring, and artificial intelligence. These offer the potential to dramatically improve insights and shape healthcare delivery. While technology development is essential, it must properly interface with clinical services to drive the maximum benefit—for providers and for patients.

Recent technology developments that provide coding and care gap notifications in electronic medical records (EMRs) offer increased potential for value-based care. These solutions address an important problem—but are incomplete as they don’t ensure conditions are coded correctly. Patients must have their conditions accurately coded to ensure health plans and providers receive appropriate compensation. Accurate coding can lead to cost-effective clinical services with the goal of improving patient outcomes.

In reality, these “technology-only” solutions may compound the problem. Providers are inundated with competing priorities and lack resources to add additional uncompensated services—a situation exacerbated by COVID-19. Current solutions cause alert fatigue and have little impact on care. They also suggest insights based on unsubstantiated data and therefore create compliance risk.

Value-based care requires a comprehensive solution

The transition to value-based care is inevitable. By 2025, it is anticipated that all Medicare Advantage and traditional Medicare plans will adopt two-sided risk alternative payment models. Fifty percent of Medicaid and commercial plans will adopt these models. This move requires providers to accurately code services for appropriate risk-adjusted reimbursement, connecting financial performance and quality of care. Success in value-based care depends on accurately assessing patient needs so that provider payments—based on the reported health conditions for that patient—will be sufficient to deliver appropriate care.

Technology cannot replace providers and clinical judgement. To drive optimal performance in value-based care, consider leveraging powerful, clinically validated technology coupled with clinical experts. By using technology combined with clinical experts, care gaps and relevant diagnostic codes can be identified. Such comprehensive services lead to more accurate coding and better performance in value-based care for both providers and health plans.

Evaluating possible solutions

There are a growing number of solutions that promise to drive value-based care performance, but very few that provide a comprehensive approach to improving risk adjustment coding and quality of care. Here are three questions to consider when evaluating various solutions:

  1. Is the risk adjustment and quality solution provider-centric? Providers need intuitive, easy-to-learn, and simple-to-use technology that seamlessly fits into their workflow, uses their EMR and intelligently mines data to optimize efficiency.
  2. Does the solution provide comprehensive in-office support? In addition to data and technology, providers need access to onsite clinicians who understand the technology and serve as an extension of their team at no cost to the practice. These clinicians can perform various tasks to reduce the burden on providers and their staff.
  3. Does the solution ensure coding accuracy and compliance? While there are “technology-only” solutions that surface codes in providers’ EMRs, they are often derived from unreliable data sources and not validated by certified clinical coders. This creates audit and compliance risk.  

How Vatica Health can help

Vatica Health is a pioneer in provider-centric technology and support solutions that directly improve clinical outcomes, efficiency, and financial performance. Vatica Health deploys clinical nurses at the point of care, armed with powerful technology. Vatica Health is accelerating the transformation to value-based care by helping providers, health plans, and patients work together to achieve better outcomes. Visit https://vaticahealth.com/ to learn more.

6 ways to ease physicians’ burden from coding, documentation and risk adjustment

By Vatica Health | February 3, 2022 | Provider, Risk Adjustment, Value-Based Care

By Shannon Lukez, Senior Vice President, Clinical Solutions, Vatica Health | This article first appeared on HFMA

The COVID-19 pandemic has heightened the need for the nation’s hospitals and health systems to gain physician cooperation in documenting and coding patient risk.

The reason is that many patients, and particularly the elderly, stopped visiting their care providers during the pandemic, often resulting in an undocumented deterioration of their health status.

Consider, for example, a 76-year-old patient with Type 2 diabetes and stage 3 chronic kidney disease, whose conditions were fully documented in the patient’s medical record and coded to the highest degree of specificity on all claims submitted in 2019. Let’s assume the patient not only refrained from visiting a physician’s office in 2020 due to COVID-19, but also was not comfortable enough with technology to receive telehealth services. Facing isolation, with severely reduced family and community support, the patient experienced growing depression and anxiety — and uncontrolled diabetes. The patient also began experiencing symptoms of high blood pressure and severely reduced access to healthy food as result of the increased financial strain brought on by the pandemic. Because the patient did not see a physician in 2020, none of this information was documented in their medical record or coded.

Undocumented deterioration in a patient’s health status impacts a healthcare organization’s revenue considerably. The absence of preventive care significantly increases the possibility for patient illness and premature death, while also depriving healthcare providers the opportunity to positively impact the patient’s life. Failure to recapture previously documented conditions, as well as new ones, leads to poor patient outcomes and lower levels of reimbursement.

The added challenge of physician burnout

Unfortunately, this heightened need for physician engagement comes at a time when many physicians are struggling with burnout exacerbated by the challenging work conditions created by the pandemic amid the ever-present risk of contracting the virus.

According to a 2021 national survey conducted by Medscape, 42% of physicians reported feeling burned out. Interestingly, 79% said the burnout started before the pandemic, with a majority (58%) citing “too many bureaucratic tasks” as the number-one cause.

These circumstances may cause many healthcare finance leaders to feel hesitant to add to physicians’ plates any kind of operational burden, particularly tasks related to enhanced coding, documentation and risk adjustment. It’s not easy to ask physicians — especially those who are salaried — to spend more time documenting conditions and reporting data for value-based payment programs while also increasing daily patient volume. Yet the financial future of a healthcare organization depends on its ability to delicately balance and accurately perform both tasks. As the industry shifts from volume-based to value-based payment models, healthcare organizations and physicians must cooperate to achieve long-term financial viability.

Consequences of physician burnout

Physician burnout is problematic because it leads to unsatisfied physicians and high turnover, which significantly affects patients. For example, burnout is associated with higher rates of major medical errors. It can also negatively affect patients’ access to and continuity of care as well as their care experience. All of these issues can harm a healthcare organization’s reputation and, in turn, its bottom line. For these reasons, physician burnout is an important ongoing concern for healthcare finance leaders.

How to foster physician engagement in capturing risk

Addressing these challenges requires a strategic approach to making coding and risk adjustment practices more physician friendly. Following are six strategies that CFOs should consider as they strive to support physicians in more accurately and documenting the risk profile of their patients.

1 Provide physicians with training on standard coding and documenting practices. One of the challenges associated with creating a risk-adjustment strategy is getting all physicians on the same page in terms of process and workflows. All too often, each practice — particularly one that’s newly acquired — will either have its own way of capturing risk or have no formal process at all. Consistency is important because it reduces the cost to operationalize the program, permits standardization of training and other key elements, and facilitates the establishment of expectations. Both the healthcare organization and the physicians will know exactly what is expected.

2 Align physician compensation with value-based care initiatives. Compensating physicians for their efforts is of paramount importance to obtaining physician buy-in and ongoing participation. Yet some healthcare executives contend that coding and documentation are simply part of the physicians’ role, so extra compensation is unnecessary.

This perspective does not consider newer models of care that focus on population health and outcomes, where revenue is largely determined by value, affordability and outcomes. And outcomes and value will be determined through analyses of claims and encounter data, which must be supported by accurate and thorough medical records documentation.

Aligning physician performance and compensation with overall organizational goals ensures shared accountability. Just as important, by thoughtfully designing compensation programs for both clinical and support staff, a health system can proactively counter the problems of physician burnout, declining retention and a growing shortage of talented physicians.

Paying physicians a base salary plus a gain-share bonus based on value-based care performance, for example, gives them an incentive to go the extra mile documenting for risk adjustment. It also sends the message to physicians that executive leaders are aware of the extra time and effort improved coding and documentation requires.

3 Optimize the electronic health record (EHR). EHRs, on their own, do not sufficiently support coding and documentation to optimize value-based care performance. However, solutions are available that optimize EHR performance to help identify care gaps and facilitate accurate coding.

Physicians need help with this process as risk adjustment coding is complex and cumbersome. In the CMS risk adjustment model alone, roughly 10,000 diagnoses are assembled into about 1,300 diagnostic groups that are then aggreged into condition categories (CCs). CCs are related clinically and with respect to cost. Hierarchies are imposed among related CCs, hence the term hierarchical condition categories or HCCs. HCCs paint a complete picture of each beneficiary’s acuity to effectively manage costs for high-risk members while ensuring they receive high-quality care and the organization receives appropriate and accurate payment.

Efficiently distilling this information for physicians reduces the burden on them and improves performance in value-based care, quality and risk adjustment initiatives. Healthcare organizations should work with their EHR vendors on ways to improve EHR performance to optimize the provider experience and patient outcomes.

4 Advocate for programs that remove operational burden associated with risk adjustment. For example, health systems could consider working with a health plan on a plan-sponsored program for primary care physicians (PCPs) that is easy to use and provides support to physicians. Such programs can combine powerful technology with clinical and administrative resources dedicated to medical practices.

These programs can help the participating health systems realize incremental revenue, improved outcomes, increased numbers of preventive health encounters (e.g., annual wellness visits) and improved overall performance in value-based care arrangements. The senior financial executive can initiate this strategy by reaching out to the organization’s managed care partners to see whether they provide this type of program and, if so, what type of performance reporting is included. Ideally, the health plan would provide real-time data so the physicians could understand care gaps for each patient and how well they are addressing those gaps.

If health plans don’t offer this option, the health system could consider developing a program internally, depend on its goals, available resources and competing priorities. In deciding whether to pursue such an approach without outside help, the organization would need to perform an in-depth assessment of the potential benefits weighed against the costs associated with the required  upfront investment and ongoing resources for program management, analytics and reporting.

Armed with the results of such an analysis, the senior finance executive can champion the effort by communicating to the health system’s C-suite the potential financial impact of a PCP-focused program to the health system, and how it could help the organization not only survive, but thrive, in the years ahead. In this way, the senior finance leader also can help demonstrate to the physicians that there is uniform buy-in at the leadership level for a program designed to help them manage the risk-adjustment process.

5 Provide support to help physicians capture and address social determinants of health. Medical care accounts for only 10% to 20% of the modifiable contributors to healthy outcomes. The other 80% to 90% are referred to as social determinants of health (SDoH) — the conditions in the environments where people grow, live, work and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Examples of SDoH include the lack of essential resources necessary to maintaining health, including housing and economic stability, literacy skills and access to nutritious food and physical activity opportunities. Because SDoH often can affect risk adjustment and, consequently, revenue, it is important for physicians to capture this information.

Healthcare organizations should assist physicians in this effort by providing a framework and support for capturing SDoH. Successful SDoH-focused programs include training clinical staff, providing access to local resources, developing workflows and promoting standard practices that help simplify the risk-adjustment process, including allocating time during patient encounters for these critical conversations.

6 Be transparent about the financial impact of physician performance in value-based care. Given the significant impact physicians have on a health system’s performance under value-based payment arrangements, executive leaders should share financial performance data with physicians (and potentially other staff as well). For some healthcare organizations, incremental revenue earned through participation in such programs can help them end the year in a financially positive position. Transparently communicating to physicians the financial impact of performance in value-based-payment contracts, including positive results attributed to quality and risk adjustment programs, builds awareness, trust and engagement.

A necessary charge

Value-based care is a strategic imperative for U.S. hospitals health systems, and it requires, first and foremost, physician engagement. Thus, although finance executives may be wary of asking physicians to take on the additional administrative tasks such contracts require, they must do so because success will depend on physicians’ absolute commitment to accurately documenting care and adjusting for risk. Although physicians may initially object to the additional work, they will likely become more receptive if they can be shown how better coding and documentation directly improves the organization’s financial performance — and how that translates into reduced pressures placed on physicians.

It is here where the finance leader can make a difference. By examining and implementing  creative and effective solutions aimed at easing the administrative burden on physicians, the senior finance executive can help them better meet the challenge of performing documentation and coding. The result is a win-win in the form of improved value-based payments and alleviated physician burnout.

Why providers face an increased challenge in understanding patient risk

During the first six months of 2020, an estimated four out of 10 adults in the United States avoided medical care because of concerns related to COVD-19. With these delays in care came missed opportunities for hospitals and health systems to capture risk and predict costs accurately.

With the rollout of the COVID-19 vaccine, some patients are slowly resuming preventive services, which is good news. Yet this trend means providers may be overwhelmed with patients whose chronic conditions have worsened or who are newly diagnosed with a chronic condition. It is of paramount importance that the provider organizations capture these diagnoses to ensure their payment is appropriately adjusted for risk.

For patients who are still not returning to their provider, it also will be important for providers to address care gaps. Telehealth may be a great way to engage these patients so that physicians can capture risk without necessitating the need for an in-person visit.

In addition, in 2020, about 8.3 million people signed up for Affordable Care Act plans that rely on risk-adjusted payment models. This is a new population of patients for whom risk adjustment suddenly matters. Many of these patients don’t have a baseline risk adjustment factor score, making it critical to capture any and all diagnoses that affect risk-adjusted payments as soon as possible.

10 year-end activities to optimize performance in value-based care

By Vatica Health | November 1, 2021 | Provider, Value-Based Care

2021 has been a challenging year for primary care physicians nationwide. They’ve risen to the challenge by remaining committed to providing value-based patient care during times of intense operational transformation and financial uncertainty. However, it hasn’t been without sacrifice. Sixty-six percent of primary care physicians say they often experience feelings of burnout. This isn’t surprising given the risks associated with COVID-19 exposure as well as the significant burden of non-clinical work that requires their time and attention. Internists, for example, spend nearly 20 hours per week on paperwork and administrative tasks. Nearly a quarter of physicians (23%) say the most challenging part of their job is navigating ever-changing managed care and regulatory compliance requirements. The silver lining is that COVID-19 cases are declining and there are solutions to help you improve clinical and financial performance.

With only a couple of months remaining in 2021, there are several steps you can take to ensure that your practice meets all performance targets and that your patients receive the highest quality of care. The good news is that most of these actions are often supported by payer-sponsored risk adjustment and quality programs that provide vital clinical and administrative support to practices. This support helps providers close care gaps, enhance coding and documentation, identify and assess social determinants, and perform patient outreach. To enhance performance under value-based care contracts, consider these 10 tips:

1. Review 2021 performance reports from payers. These reports are a treasure trove of information and identify opportunities for improvement. Common examples include patients without primary care office visits, patients for whom chronic conditions were coded in 2020 but not recaptured in 2021, patients with incomplete preventive screenings, and patients with open gaps in care. Gather internal resources and put action plans in place.

Keep in mind that data latency may result in delayed reporting. Consequently, best practice is to compare external reports with your patients’ medical records for confirmation. Your practice’s EMR may include information that has not yet been reported to managed care plans. This information may impact your performance in value-based care programs. Perform a thorough reconciliation of all data sources to ensure consistency, alignment, and accurate performance reporting for all patients.

2. Ensure all eligible patients have completed an annual preventive care office visit. Schedule annual wellness visits (AWV) and other preventive care visit types for eligible patients. These visits provide opportunities for each patient to complete their personal prevention plan and Health Risk Assessment. Annual physical exams allow physicians to address care gaps as well as proactively identify potential chronic conditions. Check patients’ records when they present for a sick visit and schedule applicable preventive visits. For patients who have not visited the office, proactive patient outreach signals that you care about their well-being and that your office is there to help. Remind them they’re due for a visit and assist with scheduling. These actions foster trust and build stronger patient-physician relationships.

3. Follow up with patients who miss scheduled appointments. Consider whether any of your patients are missing appointments or not accessing routine care due to socioeconomic barriers?

Social determinants have a significant impact on health outcomes. As such, it is important to proactively reach out to vulnerable patients and address those barriers? The American Academy of Family Physicians provides some helpful advice.

4. Follow up with patients who were referred for preventive screening but did not comply. Patients’ needs and challenges vary. While some may have forgotten about the recommended screening, others may be experiencing difficulty scheduling the appointment due to long call wait times or limited appointment availability. Others may have unanswered questions that prevent them from taking action. The best practice is to call patients directly, assess the barrier, and determine what the practice can do to help. Oftentimes, a reminder call is all that’s needed.

5. ‘Close the loop’ with specialists. Communication between primary care physicians and specialists is important to avoid fragmented care delivery and ensure patient satisfaction. Ensure care continuity by following up with any specialists to whom patients are referred. Request findings and recommended treatment plans, as applicable, an update your EMR with relevant clinical information.

6. Keep close tabs on patients with multiple chronic conditions or who are on multiple medications. Do patients take medications as prescribed? Are their chronic conditions controlled, or are they at risk of acute exacerbations? The goal is to keep patients healthy and out of the hospital. If your practice hasn’t yet started a chronic care management program, now is the time to do it. For elderly patients who are on high-risk medication regimens, conduct a thorough evaluation, and consider lower-risk alternatives.

7. Conduct patient outreach after an acute event or hospitalization. Schedule appointments to review aftercare plans and make sure patients understand and can implement these plans. Do patients understand the specialists with whom they must follow up? Do they know what medications they must take? Do they know who to contact if they have questions? Can they recognize signs and symptoms that would warrant a phone call to their doctor? These are important questions to review with your patients.

8. Evaluate office workflows. Focus on preventive care, prioritization of high-risk patients, coordination of care, and strong communication with other members of each patient’s care team. Where are the deficiencies and how can the team improve processes? Research and evaluate technology solutions that can seamlessly integrate with your office’s existing systems and improve workflows while reducing operating costs.

9. Improve documentation and coding accuracy. Schedule dedicated time for role-specific training and education that includes front office staff, medical coders, and providers. Individuals serving in each of these roles must understand how their actions (or inactions) impact the accuracy and specificity of medical record documentation and coding. This information directly impacts performance calculations, care delivery, and potential payments.

10. Leverage free external resources. External resources such as local community programs can often provide support for patients and serve as an extension of your practice through their focus on improving quality of life. For example, there are programs that can help address social determinants of health. Additionally, health plans sponsor risk adjustment and quality programs that provide clinical and administrative resources to support primary care practices. Leveraging these programs improves quality of care and patient satisfaction while reducing the burden on physicians. This, in turn, reduces the risk of burnout and attrition.

How Vatica Health can help

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 on-site or virtual licensed, clinical nurses that serve as extensions of your team at no cost to the practice. 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/.