Consider Operational Opportunities to Make the Most of Visits
Making sure that the previously mentioned pent-up demand for care has somewhere to go will help. Identify networks with capacity to address increases in demand, with an eye for those that can not only take on excess volume but do a good job from a cost and quality perspective.
Provide alerts in workflow: Make it easy for providers to support risk-adjusted by identifying gaps at the point of care – right in the electronic medical record (EMR). This is particularly helpful in shared risk opportunities.
Leverage Pre-Submission Opportunities
Identify potentially missing or incorrect diagnosis codes at the point of submission—before a claim reaches the health plan. When a provider submits the claim, they can prospectively check to ensure open gaps are considered and addressed. This allows the provider to audit their own behavior and offers the opportunity to identify gaps they may have missed.
Maximize the Impact of Chart Reviews
In the pre-pandemic world, there were approximately 240 million requests for clinical data annually. An astounding 90-94% of these requests were fulfilled manually via mail, fax, and manual uploads to portals, resulting in provider abrasion, inefficiency, and quality issues related to interoperability.
Accessing provider charts is difficult under normal circumstances, but with provider offices shut down or partially opened, and operating with limited resources, staff may not be able or willing to provide requested charts. Providers are busy with backlogged visits, which further stretches resources. The increase in missed or cancelled visits means fewer charts are available. Additionally, retrospective chart reviews have limits, and risk-adjustable diagnosis codes may go uncaptured when charts are irretrievable.
There is clearly an immediate need for alternative/ enhanced methods of retrieving medical records. While electronic retrieval of clinical care data is not new, nationwide access to the data in multiple EHRs has not been widely available until recently. Health plans must take advantage of these new solutions that help streamline and expedite data access, and simultaneously help payers retrieve a broader, more in-depth view of the member.2
Apply NLP to Risk Adjustment Coding
A recent study revealed that more than 25% of medical records contain substantiating evidence of risk factors not previously reported, which contributes to lower reimbursement for risk-bearing organizations.3
By integrating state-of-the-art natural language processing (NLP) and machine learning (ML) into the process, payers drive greater coder accuracy and productivity, improved overall efficiency, increased ROI with workflow prioritized by opportunity, and mitigated risk adjustment data validation audits through identifying coding errors and identifying unsupported claims.
The results of integrating NLP and ML into risk adjustment coding are compelling. In multiple engagements across a number of member populations, the technology has helped increase risk capture by 20-30% and elevated average correct risk category capture to 95%.4
Identify, Engage, and Support Dual Eligibles
Medicare Advantage plans can boost risk revenue with the addition of more dual-eligibles (those Medicare Advantage members who are also eligible and enrolled in Medicaid). This is an area where AI can be used to identify more duals in an identified member population. Behavioral science can be leveraged to improve engagement with these members to help them with their Medicaid application. Health plans also can consider opportunities for more valueadded services like identification of social needs to help facilitate enrollment in Medicare Part D or community-based organizations.
As policies and processes change and the pandemic exacerbates the challenges for health plans, they must employ innovative, collaborative tactics to evolve their risk adjustment strategies and keep pace with the new healthcare environment. Strategic payers will accelerate the development of a cohesive and holistic approach to risk adjustment to help improve risk scores to generate more accurate reimbursement and better-quality performance.
How Change Healthcare Can Help
For nearly two decades, Change Healthcare has helped government-sponsored health plans enhance their risk-adjusted revenue and achieve their goals. We offer the most comprehensive suite of risk and quality analytics solutions in the industry. Our diverse solutions can help health plans boost risk-adjusted revenue, improve quality ratings, and increase member and provider satisfaction through sustained engagement.
Our solutions help payers engage members based on their health status to facilitate early identification, documentation, and treatment of chronic illness.