Three Ways Health Plans Can Improve Risk Score Accuracy
By Krithika Srivats and Krishna Dharani Daliparthi
The transition to value-based care has shed light on areas of critical opportunity for financial and quality improvement—and risk adjustment is at the top of the list for payers. From physician abrasion to compliance hurdles, there are potential perils when striving to meet risk-adjustment requirements to enhance risk score accuracy. But closing technology, process, and data gaps can significantly enhance the quality, efficiency, and cost-effectiveness of the requisite medical record retrieval and hierarchical condition category coding. Following are three suggestions for improving your risk score accuracy.
1. Deploy advanced workflow and coding platforms. Technology is an enabler to transcending the natural inefficiencies built into these processes. With automated chart retrieval and coding processes, quality assurance and workflow allocation are significantly enhanced. Additionally, advanced coding platforms can employ natural language processing to automatically identify clinical concepts and terms embedded in medical records; this improves speed and accuracy over manual coding activity. Finally, the platforms can also provide complete and actionable reports and dashboards on retrieval and coding statuses along with staff-level efficiencies and key quality metrics. These innovations drive benefits such as workforce management gains of up to 60% cost savings, improved coding quality at up to 99%, enhanced turnaround time, and improved coder retention rates.
2. Maximize medical record retrieval rates by promoting provider collaboration. With the medical record retrieval essential to good risk performance, start with a custom approach. Each provider may have different preferred medical record delivery methods—onsite or remote (eg, fax, remote EMR extraction, mail, or secured drive/drop box). Understanding those requirements and showing flexibility will improve the retrieval rates significantly. It's also key to equip the call center staff with real-time status chart retrievals so they can communicate effectively with the provider office staff. Finally, provide details of every requested chart—member details, dates of services, and medical record sections—in a checklist template to the provider office staff to save time and improve retrieval rates.
3. Educate providers about CMS documentation and coding guidelines. Medical record retrieval and coding are highly challenging, due to the siloes integral to the health care payment process. Increased coding accuracy helps providers identify patients who may achieve better outcomes through individualized support services such as care management. This ensures that patients receive the appropriate level of care while supporting provider efforts to coordinate their care. In addition, risk adjustment supports providers in meeting the reporting requirements of ICD-10-CM codes, including records accuracy and timely reporting of claims and encounter data. With some straightforward processes to bridge gaps, risk scores can be improved by focusing on accurate intake of medical information. This may include provider training, including the following:
• digital training with videos presenting coding best practices;
• face-to-face trainings conducted by certified coders (and/or doctors) by presenting coding inefficiencies specific to each provider office with relevant improvement opportunities; and
• self-service education content providing information on CMS coding guidelines.
Ultimately, improvement of risk score accuracy should not be underestimated, for the impact on health plans' revenues and its role in population-based health care delivery and promulgating high-value engagement. Business process outsourcing providers can bridge payer-provider gap with lifecycle expertise. With more holistic expertise and solutions, these service providers can centralize value creation and reduce provider abrasion, enhancing relationships with providers and member/patients alike.
— Krithika Srivats is vice president of HGS Healthcare Practice Office, and Krishna Dharani Daliparthi is associate VP, HC.