- Risk Adjustment Continuum Is Premised On Payer-Provider Collaboration
- Understanding The Risk Adjustment Continuum In Changing Times
- The Importance of Payer-Provider Collaboration
- 3Ps-[Providers, Patients & Payers]: The Integral Loop Of The Risk Continuum
- Leveraging Advanced Technologies to Enhance the Continuum
- Insights for Improving Collaboration and Efficiency in the Risk Adjustment Continuum
- Conclusion
- Source
In healthcare finance, risk adjustment scores are crucial, especially within value-based settings, as they directly impact the financial sustainability of payers and providers. As profit margins tighten and payment models evolve, optimizing the value from these scores becomes imperative for success.
By 2030, the Centers for Medicare & Medicaid Services (CMS) plans to move all Medicare beneficiaries and the majority of Medicaid beneficiaries into accountable care organization (ACO) models.
Moreover, Medicare Advantage, known for lower revenue realization and higher shared risk, is expected to expand by around 60% by 2030.
A significant challenge in risk adjustment is accurately capturing patient illness burden.
Any underestimation limits revenue, hindering care, while comprehensive programs boost revenue, especially in Medicare Advantage and ACO models.
Thus, organizations that implement a collaborative, multidisciplinary approach across the entire risk adjustment continuum will be strategically poised for success in the future.
In this blog, we discuss the critical role of risk adjustment in ensuring the success of healthcare providers under value-based payment models. As CMS continues to refine its risk adjustment methods, providers and payers must embrace a multifaceted, collaborative strategy across the entire risk adjustment spectrum. While every healthcare organization may be at different stages of the risk adjustment journey, adopting these strategies represents best practices in navigating value-based payment models.
Risk Adjustment Continuum Is Premised On Payer-Provider Collaboration
Over the past decade, government and private payers have introduced various payment models to shift risk from payers to providers by focusing on value rather than volume. Healthcare finance leaders must ensure their organizations are prepared for this shift by understanding how clinical processes, quality metrics, technology, and data governance affect financial outcomes and make value-focused decisions that drive success.
The risk adjustment continuum ensures that payment models reflect patients’ actual health status and resource needs, particularly in value-based care environments. It encompasses various stages, each focusing on risk assessment and management aspects.
The shift to CMS-HCC Risk Adjustment Version 28 will reorganize categories affecting diagnoses and disease interactions. Adapting to these changes is essential for healthcare providers to maintain accuracy in risk score capture and ensure regulatory compliance in healthcare.
Not every solution provider may offer solutions covering every aspect of the risk adjustment continuum. Still, these strategies are considered best practices for payers and providers striving for excellence in risk adjustment. Together, they form the foundation of a forward-thinking approach to healthcare’s evolving landscape.
Moreover, healthcare data interoperability has long been problematic, especially in the exchange of patient records between providers and payers. According to the Council for Affordable Quality Healthcare (CAQH), information/data exchanges are hindered by substantial costs, amounting to more than $20 billion annually.
Indeed, risk-based payment models support decision-making and provide a vision and operating philosophy for value-based care and risk-based payments.
Therefore, addressing these issues is crucial to improving the risk adjustment continuum.
Understanding The Risk Adjustment Continuum In Changing Times
Healthcare organizations today rely on risk-based program efficiency, and they need comprehensive data and analytical tools for accurate risk adjustment and quality oversight.
This calls for healthcare stakeholders to deploy tools like suspect analytics to actively capture & pinpoint care gaps, resolve discrepancies, and ensure accurate documentation of condition severity for treatment.
The risk adjustment continuum in healthcare is a vital framework that helps organizations manage patient populations effectively while ensuring fair compensation for care providers.
It begins with understanding patient complexity, accounting for underlying conditions that may impact health outcomes and cost of care. By adjusting for these risks, healthcare providers can deliver personalized treatment and reduce financial disparities in care delivery.
This process involves accurate documentation and coding, such as Hierarchical Condition Categories (HCC), that capture a patient’s chronic conditions. The retrospective chart review method, combined with predictive analytics, helps healthcare providers evaluate past care and predict future health outcomes, enabling continuous care optimization.
A significant challenge for healthcare stakeholders, whether payers or providers, is ensuring the right information reaches the right members at the right time for informed decision-making.
The following key stages of the risk adjustment continuum empower both payers and providers to optimize healthcare outcomes:
- Patient Data Collection: This step involves gathering information from medical records, claims data, and patient assessments. Accurate data collection identifies chronic conditions, comorbidities, and factors influencing patient risk.
- Identifying Risk: After data collection, healthcare providers pinpoint high-risk patients by evaluating conditions leading to higher costs, often involving Hierarchical Condition Categories (HCC) coding.
- Planning annual wellness visits: Patients are categorized based on risk levels, enhancing care management strategies and focusing resources on high-risk patients, leading to precision in annual wellness visits.
- Care Coordination and Intervention: Insights from risk stratification guide healthcare organizations in designing care management plans, including disease management and preventive measures.
- Clinical Documentation and Coding: Providers must accurately document relevant diagnoses and apply correct HCC codes to claims to ensure accurate risk representation.
- Audit and Regulatory Compliance during Retrospective Review and Data Submission: Regular audits ensure documentation and Medical coding accuracy, guaranteeing the program’s compliance with evolving CMS guidelines for encounter data error management and submission processes. These processes offer detailed reporting on members’ medical events, prioritize error corrections based on risk score impact, and provide transparent visibility into potential risk scores.
- Predictive Analytics and Modeling: Advanced analytics evaluate risk scores, forecast future healthcare use, and optimize clinical data management strategies.
- Continuous Feedback and Improvement: The risk adjustment cycle includes a feedback loop, improving data collection, documentation, and care management training, leading to better patient outcomes.
Adhering to the above steps helps healthcare organizations manage patient risks, improve care quality, and secure appropriate reimbursements
GENERATE GUARANTEED ROI FROM RISK ADJUSTMENT PROGRAM
The Importance of Payer-Provider Collaboration
Collaboration between payers and providers strengthens information engagement. In healthcare, decisions rely on evidence and data, requiring practitioners and patients to consider medical knowledge alongside case-specific information. Health outcomes improve when providers have timely access to the right data for the right patient at the point of care, along with informed and engaged patients. This is made possible through pre-visit data sharing between providers and, more critically, through the vital contribution of payers in sharing information with providers and patients.
3Ps-[Providers, Patients & Payers]: The Integral Loop Of The Risk Continuum
Exchanging Clinical data securely across healthcare systems fosters collaboration among care providers.
Imagine a primary care physician eagerly checking the latest updates on a patient’s condition from an orthopedist. As this happens, the payer steps in with timely news, informing the provider and the patient about the green light for physical therapy and detailing the number of visits approved. With this crucial information in hand, the primary care physician can craft a well-informed follow-up plan, setting the stage for the best possible outcomes for the patient.
This process also helps patients stay actively involved in their care, potentially preventing further complications. Electronic data exchange ( integrated EHRs ) ensures that providers remain well-informed using their respective information systems.
By incorporating data from payers, the patient’s profile is made more complete, facilitating treatment that considers a comprehensive view of their health and associated social or economic factors, thus assuring care quality.
Leveraging Advanced Technologies to Enhance the Continuum
Under risk-based contracts, payer and provider groups can invest in technologies that improve performance. For instance, RAAPID’s Neuro-Symbolic AI assisted previsit and point-of-care platform allow clinical teams to review a patient’s medical history before an appointment and during a visit by an EHR-agnostic platform, ensuring precare teams and physicians have actionable information during the patient visit.
Furthermore, vendors specializing in API implementation can position themselves as leaders in healthcare innovation by offering cross-platform APIs with diverse applications across clinical systems . Retrospective processes can also be enhanced by outsourcing coding to vendors that utilize machine learning and clinical natural language processing (NLP) in retrospective review, ensuring evidence-based high accuracy and efficient medical coding validation.
As Such, it is interesting to note that although the risk adjustment solution space is deep & wide, offering a range of solutions for healthcare providers and payers. The specific solution needed depends on the customer’s unique situation or scenario. Moreover, not always every solution will be available with every vendor, so a combination of solutions can come from various vendors specializing in risk adjustment. Therefore, it is logical to outsource risk adjustment solutions to multiple vendors tailored to meet specific needs.. Nevertheless, the abovementioned solutions provide a strong foundation for a progressive approach to the constantly evolving risk adjustment landscape.
Insights for Improving Collaboration and Efficiency in the Risk Adjustment Continuum
- Develop Contracts that Align Incentives and Reward Value: Leverage risk-adjusted data to set equitable prices, minimize patient cost-sharing, and manage chronic diseases effectively.
- Invest in Technology: Strategic investments in advanced technology demonstrate value and support grouping and classification methodologies, quality measurements, and care management analytics.
- Share Information with Frontline Care Providers: Provide clinicians with longitudinal patient records to view patients’ histories comprehensively. Use predictive analytics to identify high-risk patients and share insights with physicians.
- Establish a strategic roadmap for embracing risk in the long term:
Payers assess a provider’s readiness for downside risk in value-based care models using factors like population size and quality metrics related to preventive services and managing chronic conditions. Newcomers start with upside-only contracts, sharing savings without responsibility for excess costs. Over time, they transition to downside-risk arrangements, sharing both savings and costs, fostering operational independence in shared-savings models.
Conclusion
Achieving success in risk adjustment requires a comprehensive, data-driven approach that fosters payer-provider collaboration. Organizations can enhance care outcomes, ensure accurate risk scoring, and optimize financial performance by leveraging advanced technologies, improving data exchange, and aligning incentives with value-based care. For payers & providers, embracing a multidisciplinary strategy will be crucial for thriving under evolving payment models and meeting healthcare’s future demands.
Albeit only some vendors may be able to offer the complete set of tools and technologies, the comprehensive strategy outlined in this blog continues to serve as the benchmark for achieving optimal patient outcomes in the evolving risk adjustment continuum.
Source
ENSURE COMPLIANCE AND PASS RADV AUDITS WITH NLP TECHNOLOGY
