Tag: compliance

Medical group improves risk accuracy and closes care gaps

Healthcare providers are under greater pressure than ever before and are forced to manage various competing demands for their time and attention. As the transition to value-based care accelerates, so does the need to collaborate with health plans to ensure complete, accurate coding and documentation to inform better risk adjustment and for Primary Care Physicians (PCPs) to actively identify and close care gaps. Patients also want (and deserve) quality healthcare interactions that recognize their unique needs, conditions and circumstances.

Against this backdrop, a lot is riding on the annual patient visit. Amid packed schedules, PCPs need to assess risk, address HEDIS gaps and ensure their patient is properly heard and cared for, with all questions answered and concerns addressed. 

At the same time, PCPs are chronically short on time and resources needed to complete required coding and documentation—often putting in two extra hours a day just to get through EMR backlogs. The continued rollout of CMS-HCC Model V28 will require even greater coding expertise and scrutiny, a troubling proposition for already-strapped providers who are facing burnout at alarming rates. 

Fortunately, by prioritizing and embracing accurate diagnosis coding—and drawing on expert partners like Vatica Health to help upskill PCPs and relieve the admin burden—providers can better identify and manage patient risks, close gaps in care, stay in compliance with evolving guidelines and, ultimately, thrive in a value-based care world. 

General Physician, PC, one of the largest and most respected medical groups serving Western New York and Northern Pennsylvania, has made it their mission to deliver quality care that’s second to none. Vatica partners with General Physician, PC to overcome the mounting complexity of risk adjustment and lessen the load associated with coding and documentation.

At the 2024 RISE Conference, Richard Charles, MD, Chief Medical Officer and Physician Lead for General Physician, PC, shared his group’s Vatica journey and the role accurate and complete coding and documentation play in helping close care gaps and deliver top-notch care. 

Dr. Charles’ PCPs—like many—needed support on the risk adjustment journey. Dr. Charles and Vatica knew they needed to shift the group’s perceptions that risk adjustment is a benefit only for health insurers and engage the team purposefully in striving for accurate coding and documentation. “There’s been considerable education of our providers around risk assessment,” says Dr. Charles. 

As providers continue to evolve their approaches and protocols in the name of value-based care, continued coaching and education around the upsides of improved risk adjustment—fair and accurate compensation, greater continuity of care, more proactive and higher-quality interactions and more—will separate the leaders from the pack.

“There’s been considerable education of our providers around risk assessment.” 

— Richard Charles, MD, Chief Medical Officer and Physician Lead, General Physician, PC

Vatica provides clinical teams plus user-friendly technology at the point of care to enable PCPs at General Physician, PC to capture more accurate and complete diagnostic codes, which helps optimize risk adjustment and leads to accurate CMS reimbursement. A prospective program not only benefits health plans—it helps providers proactively manage care with a comprehensive pre-visit workup of all active and suspect conditions aggregated from various sources. 

Curating only validated conditions and codes prior to the encounter, Vatica empowers PCPs to address HEDIS gaps through necessary interventions, like screenings or medication adherence, and 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,” Dr. Charles explains. “It helps our providers build trust with patients.” 

Vatica also provides group training, one-on-one education and CME courses to help PCPs and their teams understand and overcome the complexities of coding and capitalize on the benefits of better risk adjustment. 

Dr. Charles cites a 10% improvement in risk score accuracy since General Physician, PC partnered with Vatica. He also found specific improvements in hemoglobin A1C levels and blood pressure control, attributed in part to Vatica’s process. “There’s a tremendous improvement in how many HEDIS gaps and how many other care gaps we’ve closed,” he says. 

“There’s a tremendous improvement in how many HEDIS gaps and how many other care gaps we’ve closed.” 

— Richard Charles, MD, Chief Medical Officer and Physician Lead, General Physician, PC

Figure 1: YoY Performance 2021–2023

General Physician, PC has capitalized on improved risk adjustment by using the newly captured revenue to offer additional services. These services give physicians valuable resources to help patients address issues and more time to focus on other clinical tasks and priorities. “We have a large clinical pharmacy program that addresses polypharmacy, high-risk drugs, transition of care, diabetes. We have nutrition, behavioral health, all of which are funded from these dollars,” explains Dr. Charles. “When a patient hears about all the services you have, they become more engaged.”

“We have a large clinical pharmacy program…nutrition, behavioral health, all of which are funded from these dollars.” 

— Dr. Richard Charles, Chief Medical Officer and Physician Lead, General Physician, PC

Accurate and complete coding benefits the provider, the practice and the patient. With Vatica as part of its risk adjustment protocol and clinic ecosystem, General Physician, PC has reduced the administrative burden on its team and optimized its diagnosis coding practices. And for Dr. Charles, that goes well beyond time savings or even compliance: “We want to take great care of these conditions, not just document that [patients] have them,” he concludes. 

Maximizing quality of care. Minimizing admin load.

Effective risk adjustment drives value-based care performance and promotes fairness and equity in the Medicare Advantage (MA) program by ensuring that payments to health insurance plans and providers reflect the health status and needs of the patients. 

The keyword here is effective. For risk adjustment to deliver on its purpose and its promise, all parties involved—patients, providers and payers—must be coordinated and aligned. The trouble is, legacy programs, such as Health Risk Assessments (HRAs) completed by in-home assessment vendors, remain disconnected from treating providers. While HRAs can be a helpful tool in identifying active conditions, diagnoses captured in HRAs are often not recorded in a subsequent medical visit. Detached programs and practices can undermine the purpose of risk adjustment, increase the risk of non-compliance with evolving regulatory requirements and fail to adequately support and incentivize providers in their transition to value-based care (VBC).

The modern healthcare ecosystem is increasingly complex. Risk adjustment programs that exclude the Primary Care Physician (PCP) are inefficient, create provider-patient friction and amplify risk. Physicians and their teams need a risk adjustment solution that makes coding and documentation easier and leads to high-quality outcomes for their practice and their patients.

Here’s how Vatica Health’s one-of-a-kind risk adjustment and quality of care solution can complement current coding and documentation processes and enhance risk adjustment without overextending staff or sacrificing precious time and resources. 

Why it matters

Accurate coding is the backbone of effective risk adjustment, ensuring risk scores are calculated correctly and reflect the true health status of enrollees. HRAs, typically performed in-home by vendors on behalf of MA plans, can lead to inflated HCC scores and compromised care.

How Vatica delivers

  • Point-of-care integration: Vatica works at the point of care and proactively surfaces the most appropriate and up-to-date conditions for PCPs to validate. Physicians can focus on their patient interaction, knowing they have a complete and accurate picture of the patient’s conditions.
  • Holistic data collection: Unlike other solutions, Vatica collects and analyzes data from various sources, as well as unstructured data, including consult notes and medical images, offering a more comprehensive picture of a patient’s health. No need for PCPs to connect the dots between various systems and sources.
  • Clinical review: With Vatica, 100% of patient encounters are reviewed by clinicians, such as RNs with advanced coding certifications. This ensures accuracy, completeness and compliance—and offers peace of mind for PCPs.

Why it matters

Any risk adjustment solution that providers adopt needs to reduce friction, not add to the already taxing administrative load. A flexible and user-friendly solution that meets PCPs where they are ensures effective and robust use, promoting better outcomes for everyone.

How Vatica delivers

  • Provider-centric approach: Comprehensive pre-encounter work performed by Vatica clinicians arms providers with the most clinically relevant information to deliver the highest quality of care during patient visits. Providers remain at the center of care to diagnose, document and follow up.
  • Workflow compatibility: Vatica’s EMR-independent technology works within existing workflows, meeting providers where, how and when they work. 
  • Administrative support: The unique Vatica model includes expert clinician coding support, allowing PCPs more time to deliver high-quality care and assuring that coding and documentation will be accurate, complete and compliant.
  • Payer-agnostic: Vatica is payer-agnostic. Clients include most national health plans and many regional plans. 

Why it matters

Accurate risk adjustment is a cornerstone of value-based care. Continuing to rely on legacy programs like HRAs and chart reviews that might not reflect the true status of health—and can lead to inflated HCC scores and inaccurate risk-adjusted payments—flies in the face of VBC principles and sets providers back in their journey.

How Vatica delivers

  • Help in identifying care gaps: Vatica flags open HCC coding and care gaps for PCPs to address during encounters. Real-time clinical data assists providers in addressing HEDIS measures during their interaction.
  • Accurate VBC benchmarking: Vatica empowers providers to make the PCP visit the foundation for VBC benchmark accuracy. PCPs can deliver continuous, more effective care and build stronger patient relationships. 
  • Revenue opportunities: Vatica helps PCPs earn additional revenue through reimbursable visits, health plan incentives and enhanced VBC performance.

Vatica Health’s Best in KLAS® risk adjustment solution is designed to help health plans, providers and patients achieve better outcomes, together. By increasing patient engagement and wellness, improving coding accuracy and compliance, and helping identify and close gaps in care, Vatica helps ensure that everyone benefits.

A wave of CMS regulatory changes – a new paradigm for 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 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/.