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Best Practices for Health Plans to Run a Profitable & Compliant Risk Adjustment Program

Healthcare Plans are in constant flux, making it vital for Medicare Advantage Organizations (MAOs) and medical groups to keep their finger on the pulse of risk adjustments. Millions of Medicare Advantage medical charts are meticulously coded each year, highlighting the crucial need to get a full picture of each member’s health status. This continuous effort ensures that risk is precisely and efficiently managed, echoing the ever-changing healthcare landscape.

Risk Adjustment Program – Charting the Crucial Path for MAOs

MAOs encounter many challenges in risk adjustment, particularly concerning provider documentation and coding. While providers excel in documentation, the accurate capture and coding of chronic conditions often pose significant hurdles. This disjunction between documentation and coding underscores the importance of retrospective chart review, a process through which MAOs strive to bridge the gap and enhance risk adjustment efficiency.

In the Medicare Advantage Organizations (MAOs) world, there’s a consistent focus on diving deep into retrospective risk adjustment chart reviews. But why? Well, it all boils down to the RAF (risk adjustment factor) scores. These scores are the linchpin, essentially shaping the reimbursement landscape for MAOs.

So, how do they ensure precision in these payments? Through meticulous retrospective chart reviews, where encounter data is meticulously aligned with patients’ medical records. It’s not just about checking boxes; it’s about ensuring that MAOs accurately compensate for the care provided to those with more complex healthcare needs. These reviews accurately depict healthcare costs, ensuring that each beneficiary receives the right level of care and support they truly need.

The primary risk adjustment outcomes for hierarchical condition category (HCC) assessment are based on the retrospective chart review process. From Prospective Review, designed to anticipate future patient encounters, to Concurrent Review, which entails real-time analysis, and Retrospective Review, focusing on past code accuracy, each step contributes to refining risk adjustment strategies and optimizing reimbursement outcomes.

Unveiling Insights through Retrospective Audits

Retrospective audits, often conducted by third parties, offer invaluable insights into documentation and coding efficiency and accuracy.

By providing unbiased evaluations, these audits empower providers to implement corrective measures and refine documentation practices, ensuring compliance and accuracy for future visits.

As we navigate the intricacies of documentation, coding, and reimbursement, let us examine the dynamics of risk adjustment to drive excellence in healthcare delivery and ensure equitable compensation for the care provided.

Join us in this transformative discussion as we explore innovative risk adjustment approaches.


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Advancing risk adjustment operations: Top-tier Practices for health plans

Health plans risk inaccurate reimbursements relative to their populations’ risk levels. Data analytics in risk adjustment unveil 40-59% more revenue per chart compared to self-identified cases. Some CMS eligibility categories aim to tackle dual-eligible reporting hurdles, projecting a certain percentage of risk score dip for Medicare Advantage plans with more partial duals. Detecting underreported conditions can counterbalance or reverse this decline.

1. Understand what the most recent regulations entail

CMS releases advance notices to alert plans about forthcoming changes to the risk adjustment program. By staying informed and strategizing early, plans can adapt to the latest updates and ensure they’re well-prepared for upcoming risk adjustment modalities.

2. Remain engaged and maintain communication with CMS

CMS frequently seeks public feedback before implementing new policies, valuing input for thorough consideration. Responding allows you to express how policies affect your plan, and CMS often shares highlights of comments, offering insights into others’ responses. Engaging ensures your plan’s voice is heard in policy development.

3. Launch outreach campaigns at an early juncture

Empower members to engage with primary care providers and educate them on Medicare risk adjustment guidelines. Early comprehensive health evaluations can address various conditions and care gaps, crucial for identifying members eligible for disease management programs. Prioritizing proactive healthcare fosters better outcomes and cost-effective management.

4. Familiarize yourself with your demographic

A thorough understanding of your population enabled by suspect analytics helps identify members with undiagnosed conditions for targeted interventions.
A prioritized approach ensures accurate risk assessment and proactive outreach for improved healthcare outcomes.

Try to answer the below with as much accuracy as possible.
  • For which conditions must you prepare and provide care?
  • To what extent are they (target population) ill?
  • Which patients carry the greatest risk?

5. Exercise strategic judgment in suspecting

Utilize between February and April to avoid targeting low-risk members and enhance precision. Identify specific members, retrieve records, and document conditions for final CMS assessment in January.

6. Aim for maximum efficiency when retrieving medical records

Efficient retrieval ensures timely access to relevant patient information for accurate coding and billing.

Streamlined systems, technology integration, and clear communication optimize retrieval processes, enhancing operational efficiency.

Referencing a patient’s medical record is vital for confirming and documenting potential conditions

Patient records serve as crucial documentation, even if conditions aren’t billed during specific encounters. Clear protocols, effective communication with providers, and phased retrieval strategies ensure comprehensive record referencing.

7. Ensure precise coding for Chase list charting accurately

Focus on accurately capturing all diagnoses and HCC data during the Chase listing process. Emphasize accuracy to your coding team. Minor errors can lead to significant financial impacts, especially during audits and across populations.

8. Gather, cleanse, and thoroughly validate your data

Ensure high quality and accuracy before submitting data to CMS .

Adapt processes and address challenges related to the V24 TO V28 transition, as new coding protocols may impact data quality, to maintain accuracy.

9. Confirm that data is submitted promptly and in the right format

Train staff on CMS requirements, and coding practices, and conduct regular data accuracy audits. Ensure correct data capture and formatting, establish submission protocols, and maintain CMS communication.

10. Correct any mistakes and evaluate your final reports meticulously

Every year presents a fresh chance to secure suitable funding for your population. The last step entails rectifying any errors, analyzing your final data, and exploring avenues to enhance your submissions.

MAOs: Reaping the Rewards of Risk Adjustment

Risk Adjustment Facilitates Audits for MAOs

With heightened focus on the comprehensiveness and accuracy of data submitted for risk adjustment. MAOs are investing a lot of money in chart reviews for better ROI. It’s clear the documentation must be robust enough for more effective risk adjustment coding.

External audits by CMS, along with OIG and RADV audit preparation tasks, require accurate data submission to government agencies. Internal data validation reviews and Claims Verification services assess the accuracy of submitted hierarchical condition categories (HCC), ensuring compliance and improving care quality through comprehensive analysis and performance insights.

Claims Verification service is a process for reviewing the accuracy of hierarchical condition categories (HCC) submitted by claim data and comparing them to coding results.

Health plans and providers conduct claim audits to verify correct diagnosis codes, using retrospective audits to capture past opportunities and prospective audits to identify coding issues for future premiums. Third-party retrospective audits provide unbiased documentation and coding accuracy evaluations, enabling providers to improve future records.

These risk adjustment services offer in-depth analysis reports on claims processing activities and insights into clinical performance trends. They help healthcare management providers to be in sync with regulatory changes and improve quality metrics at all levels of care delivery. Both prospective and retrospective charts to be evaluated for eligibility.

Rationalized  Reimbursements  for better revenue

Retrospective risk adjustment ensures healthcare providers receive fair compensation by rectifying coding gaps. Errors in medical billing are common, risking financial loss or compliance breaches. Retrospective reviews scrutinize past claims, revealing missed or inaccurately documented HCC codes.

This process uncovers recurring documentation problems, prompting corrective action and resubmitting accurate codes. Identifying missed diagnoses and reporting additional Accurate HCC submissions can boost revenue. RAAPID’s AI-powered Solution tackles these challenges with precise coding, robust analytics, and an audit defense tool, securing reliable, auditable results and optimizing revenue for Medicare Advantage plans.

Drives Compliance & seeks audit readiness

The historical reliance on chart reviews for capturing supplemental codes has yielded financial benefits for most plans. However, regarding compliance, Medicare Advantage Organizations (MAOs) face a critical imperative: deleting unsubstantiated diagnosis codes is paramount to avoid overpayments and potential liability issues with CMS. Prioritizing the retrieval of high-priority charts, particularly those pivotal in the origination of Hierarchical Condition Categories (HCCs), is advised.

Adherence to coding guidelines is indispensable for maintaining Healthcare compliance audit standards. CMS’s stringent submission rules underscore the importance of accuracy regarding beneficiary details, provider type, service dates, and valid signatures, ensuring compliance at every step of the submission process.

Proactively submitting comprehensive charts and reviewing results to detect trends are fundamental strategies for MAOs to ensure stringent compliance with CMS regulations while optimizing audit outcomes.

The Promise of AI – Shifting Gears from Inefficiency to Streamlined robust Performance

1. Transforming Healthcare Auditing with NLP Technology

Integrating NLP technology in healthcare augments retrospective solutions to mark a new era in auditing by automating processes, enhancing data quality, and revolutionizing risk adjustment coding for greater efficiency and accuracy.

2. Automating and Enhancing Data Quality with Neuro-symbolic AI in healthcare

RAAPID’s AI-powered solution minimizes manual coding errors by precisely extracting data from various sources. The application of Neuro-symbolic AI in healthcare supports clinical Automation to streamline chart reviews and audits, saving time and money while ensuring data accuracy and consistency.

3. Improving Compliance and Efficiency with Advanced Analytics

Data-driven risk adjustment solutions enhance auditing transparency and ensure HIPAA compliance. Smart suspect analytics, combined with other advanced risk adjustment coding tools, detect early issues, enabling health plans to address compliance gaps, reduce audit liabilities, and optimize resource allocation effectively.

RAAPID: Your Risk Adjustment Partner 

We’re not just another vendor but your strategic partner in risk adjustment success. 

Our AI-driven platform goes beyond traditional solutions, offering: 

  • Automated Coding Validation: Minimize errors and ensure accuracy. 
  • Intelligent Chase List Prioritization: Focus your efforts on the most impactful cases.
  • Actionable Insights: Identify care gaps and improve member outcomes. 

Ready to transform your risk adjustment program? 

Let’s talk. Schedule a demo with us today and discover how we can help you unlock the full potential of your MA plan.

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Disclaimer: All the information, views, and opinions expressed in this blog are inspired by Healthcare IT industry trends, guidelines, and their respective web sources and are aligned with the technology innovation, products, and solutions that RAAPID offers to the Risk adjustment market space in the US.