The arrival of new regulations such as the RADV Final Rule and the 2023 Final Rate Notice has led to growing concerns within the industry. Lately, numerous healthcare and risk adjustment forums have been held, where speakers have highlighted significant compliance and care quality challenges. These new regulations have created a shared urgency to address these issues to ensure the industry’s continued success.
Table of Content:
- Why Risk Adjustment Matters To Primary Care Physicians (PCPs)
- Recent Challenges Facing PCPs
- Mitigating PCP Barriers: Methods, Tools & More
- Mixed Strategy: Maximizing Care Quality, Minimizing Admin Load
- Why It Matters
- Identifying Care Gaps: Solution Providers to the Aid of Practitioners
- PCP-centric risk adjustment: Predicated on Meaningfully Engaging Physicians
- Finding Common Ground: Fostering Patient-Provider Synergy for PCPs
- How We Do It
- Better Risk Adjustment Benefits Everyone, including PCPs
- Conclusion
Why Risk Adjustment Matters To Primary Care Physicians (PCPs)
As policymakers and payers transition to value-based care, primary care physicians (PCPs) are encountering new financial risks for their patients. With capitation rates established, ensuring fair compensation has become increasingly pressing. The need to develop methods that accurately account for patient risk differences is now critical, highlighting the importance of precise risk adjustment to support the sustainability of primary care organizations(PCOs).
In this blog, we will discuss how the pairing of expert clinical teams with cutting-edge risk adjustment technology increases patient engagement and audit preparedness, improves coding accuracy and compliance, identifies and closes gaps in primary care, and enhances communication and collaboration between providers and health plans.
Recent Challenges Facing PCPs
Patients with complex healthcare needs are at risk of negative outcomes due to fragmented and delayed care, which can diminish their well-being and drive up healthcare costs. Health reform initiatives, particularly in primary care, aim to address these risks by more effectively directing resources to those who need them most.
Nevertheless, identifying individuals at high risk for adverse outcomes, such as unplanned hospitalizations, emergency department visits, or other potentially preventable costs, is challenging. Additionally, providing intensive resource allocation to every patient is neither feasible nor efficient.
Mitigating PCP Barriers: Methods, Tools & More
To accurately assess the needs and costs of delivering high-quality care to patients with complex conditions, risk adjustment must address unmet and under-met needs rather than just focusing on existing chronic disease burdens. Tools like the Area Deprivation Index and Social Deprivation Index can identify regions in need of additional health resources. While these indices hold the potential for effective risk adjustment, they are not yet widely adopted.
Additionally, the healthcare landscape is becoming increasingly intricate. Healthcare programs that exclude Primary Care Physician Role in Risk Adjustment tend to be inefficient, create friction between providers and patients, and heighten risks. Thus, physicians and their teams need a risk adjustment solution that simplifies compliant coding and documentation while ensuring financial Performance along with high-quality outcomes for their practice and patients.
WANT TO PERFORM A 2ND LEVEL CHART REVIEW BEFORE CLAIM DATA SUBMISSIONS TO CMS
Mixed Strategy: Maximizing Care Quality, Minimizing Admin Load
Health plans are increasingly valuing PCP-centric risk adjustment prospective programs for their ability to deliver real-time impact at the point of care, unlike retrospective programs that rely on chart reviews. Primary Care Physician Role in Risk Adjustment programs enable timely interventions, identify care gaps, and ensure accurate documentation and compliant coding.
Conversely, retrospective programs often face challenges in effectiveness and alignment with modern, outcome-based financial performance optimization models. Hence, the most efficient approach is to integrate both methods, focusing on prospective interventions to save time and reduce administrative burdens while also incorporating some retrospective data reviews to effectively engage primary care physicians.
Why It Matters
Without the blended approach discussed above, clinicians managing more complex and higher-risk populations may face inadequate compensation and unfair comparisons with their peers. A suitable risk adjustment framework must benefit accountable care organizations that are required to deliver high-quality, compliant primary care as per CMS standards but lack the necessary tools.
For PCP-centric risk adjustment to fulfill its intended goals, all stakeholders—patients, providers, and payers—must be well-coordinated and aligned. However, legacy programs, such as Health Risk Assessments (HRAs) conducted by in-home assessment vendors, often remain disconnected from PCPs.
While HRAs can be useful for identifying active conditions, the diagnoses noted in HRAs are frequently not recorded during subsequent medical visits. This disconnect can undermine the effectiveness of risk adjustment, increase the risk of non-compliance with evolving regulations, and fail to adequately support and incentivize PCPs as they transition from fee-for-service to value-based care (VBC).
Identifying Care Gaps: Solution Providers to the Aid of Practitioners
While Primary Care Physician Role in Risk Adjustment are more operationally complex to implement, they are preferred for their powerful impact on behavior at the point of care. This approach offers significant benefits, including higher overall value, better return on investment, and reduced healthcare compliance risk.
An ideal PCP-centric risk adjustment solution provider identifies open HCC coding and care gaps for Primary Care Practitioners (PCPs) to address during patient encounters. Real-time clinical data helps providers meet HEDIS measures during these interactions. The solution provider also supports PCPs in generating additional revenue through reimbursable visits, health plan incentives, and improved performance in value-based care (VBC).
When combined with PCP engagement, prospective risk adjustment proves to be the most effective method for gaining a comprehensive understanding of a population’s disease burden. It also enables accurate forecasting of care costs for Medicare Advantage, the Medicare Shared Savings Program, and commercial lines of business.
PCP-centric risk adjustment: Predicated on Meaningfully Engaging Physicians
Ideally, health plans and physicians would work together to cut costs and enhance health outcomes, with members actively scheduling preventive visits. However, true engagement among all stakeholders is rare. Effective physician engagement needs timely support, including dedicated clinical resources to streamline coding and identify care gaps.
Support staff, easy-to-use technology, and aligned financial incentives are also crucial. Additionally, member engagement is vital, as physicians are more motivated by PCP-centric risk adjustment programs that significantly improve patient outcomes and preventive care.
Finding Common Ground: Fostering Patient-Provider Synergy for PCPs
RAAPID prioritizes compliance and adopts a physician-centered approach to risk adjustment and clinical quality. We combine clinical expertise with advanced technology to support physicians directly at the point of care. By performing automated QA Review using AI/NLP technology on the medical charts & HCC coding we provide a thorough and comprehensive clinical view of each patient.
Our state-of-the-art Knowledge Graph and clinical Neuro-Symbolic AI in Healthcare technology drive improved outcomes. Our end to end risk adjustment solution includes automatic code suggestions, enhanced chart reviews with improved chase lists prioritization, superior code validations, and actionable clinical insights.
How We Do It
- Holistic Data Collection: Our advanced NLP solution collects and analyzes data from various sources, including EHR or EMRs, and unstructured data such as clinical charts, consult notes and medical images. Our computer vision model(s) process only the essential information from tables and OCRs, providing a more accurate and comprehensive view of a patient’s health. All this eliminates the need for PCPs to connect data from multiple systems.
- Catch It Where It Happens: Our Prospective Previsit Solution is an AI-powered solution that uses NLP to analyze patients’ 360-degree longitudinal data, including charts, claims, lab reports, and pharmacy records, to identify chronic conditions with supporting MEAT evidence, paving the way for EHR-agnostic capabilities in the near future.
- Point-of-Care Integration: When connected with EHR, RAAPID operates at the point of care, proactively surfacing the most relevant and up-to-date conditions for PCPs to validate. This approach allows physicians to confidently focus on patient interaction, knowing they have a complete and accurate understanding of the patient’s conditions, ensuring accuracy, completeness, and compliance, and giving PCPs peace of mind.
Better Risk Adjustment Benefits Everyone, including PCPs
Our attention to healthcare documentation accuracy and coding validation through quality improvement processes improves accuracy and reduces compliance risk. We work closely with practice teams to develop a custom workflow and process, achieving an ideal state that yields the best results with the least amount of effort for PCPs.
By enhancing patient engagement and wellness, optimizing coding accuracy and compliance, and aiding in identifying and closing care gaps, we ensure that all stakeholders benefit.
Conclusion
In summary, addressing the new regulations and financial pressures pertaining to the Primary Care Physician’s Role in Risk Adjustment requires a strategic approach. RAAPID’s innovative solution integrates advanced technology with real-time data analysis, ensuring accurate documentation and optimal reimbursement. By combining prospective and retrospective methods it simplifies administrative tasks and enhances patient care. This comprehensive approach not only supports compliance but also strengthens the overall effectiveness of primary care, benefiting all stakeholders involved.
We encourage readers to discover how AI-based advanced NLP technology is transforming the future of clinical analysis and risk adjustment.
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