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Navigating ROI Compliance: Risk Adjustment Vendor Selection Criteria Checklist

Making a choice: overburdening or outsourcing?

Do you find yourself overwhelmed by submission deadlines?

Do you struggle with managing the growing array of compliance parameters required to achieve a satisfactory ROI? 

Moreover, the Centers for Medicare and Medicaid Services (CMS) have heightened scrutiny of insurers, adding pressure on organizations aiming to safeguard Medicare and bolster the MA program.

If you’re still confused about outsourcing your risk adjustment services, we understand your concerns.

In this blog, we’ll explain how outsourcing risk adjustment services can help you ensure accurate and timely data submission to CMS, allowing you to focus on your risk adjustment priorities, ensure compliance, and maximize revenue.

As we proceed, let’s explore the typical scenarios to help us assimilate/decode when to outsource HCC risk adjustment coding services.

  • Scenario 1:
    Ensuring consistent quality and coding accuracy: The need for flexibility in ensuring consistent quality and accuracy in medical coding services, regardless of increased or decreased workload dynamics, So, unlike an in-house coding department with a small team size, outsourcing offers a large and flexible team of cross-qualified and experienced experts.
  •  Scenario 2:
    Core activities take priority: Using time and resources for in-house medical coding diverts from core activities. The lack of bandwidth to train and manage coding staff can delay project activities. Outsourcing coding operations reallocates time and resources for core activities like patient management and care quality to proceed without any delays or impediments.
  • Scenario 3:
    Vying for qualified medical coders: Facing a shortage of qualified medical coders, exacerbated by the transition to ICD-10 and workforce attrition cycles, makes it difficult to find experienced coders.
  • Scenario 4:
    Challenges in developing in-house technologies: Management may want to focus more on investing in core areas, such as improving patient care, instead of developing in-house technologies requiring tech experts and specialized maintenance teams. Outsourcing tech requirements could be a more practical option. 

When it comes to outsourcing a risk adjustment solution provider, it’s crucial to choose a compliant and ROI-focused service. So, let’s dive in and explore the options to help you make the best decision for your business. Are you ready?  Let’s find out!  Take the quiz, and we’ll know.


Selection Process Strategy

We are glad to learn your perspective via the aforementioned quiz; indeed, it expands our horizons and allows new learning to set in. With that in mind, before we delve into vendor selection criteria, let’s discuss the prime best practices of the vendor selection process.

These act as a roadmap for considering a wide range of factors and criteria when choosing a risk adjustment vendor.

  • Best Practices: Risk Adjustment Vendor Selection Process
    The vendor selection process can take several months to complete, and switching vendors may temporarily halt business operations and lead to duplicate documentation. It starts by sending out RFPs and RFQs to identify potential vendors.
  • Preliminary basic assessment
    Vendor assessment begins with a basic understanding of past achievements, current capabilities, pricing, and overall service quality. This lets you identify potential vendors and match the best ones against your specific risk adjustment solution provider selection criteria list.
  • Mapping vendor capabilities with program requirements
    The risk adjustment vendor selection process isn’t a one-size-fits-all approach, as it addresses distinct clinical workflow areas, multiple departments, and dynamic operational volume. More importantly, it aims to map mutually achievable project milestones aligned with organizational objectives.
  • Analyzing vendor offerings post-mapping.
    When selecting a risk adjustment vendor, it’s important to approach the process thoughtfully. Doing so can help ensure long-term success, mitigate risks, and add value to risk adjustment operations. By carefully analyzing various criteria, you can make a solid choice that aligns with your risk adjustment goals and needs.
  • Contract negotiation
     It is critical to consider how negotiations should proceed based on the selection criteria, ultimately leading to the final (vendor) selection. After signing the contract, it is crucial to continuously monitor and measure the vendor’s performance to confirm that the designated selection criteria are effectively selecting the most suitable risk adjustment solution provider.
  • Relationship building 
    Vendor selection isn’t just about efficiency and fostering solid, beneficial relationships. These mutual relationships are vital for enhancing organizational performance, competitiveness, and future collaboration.

Now that we have covered the basics of the vendor selection process, as discussed above,
we can put the pieces together and understand the many pros and cons of outsourcing.
You should carefully weigh all these factors before choosing outsourcing as your preferred approach.

This indeed leads us to the core topic of our blog, i.e., vendor selection criteria, which we shall discuss in detail below.

This article focuses on the vendor selection criteria for HCC risk adjustment coding services.

When selecting a vendor to manage your risk adjustment needs, the most important consideration is that the vendor must have a thorough understanding of the industry’s nuances.

Selecting a vendor who can demonstrate a deep understanding of risk adjustment methodologies is crucial, especially for a full-stack risk adjustment solution that caters to the broader risk adjustment process mentioned earlier.

  • Accurate HCC Coding>> For Optimized RAF Score and Better Care Quality.
  • Chase List Prioritization >> For High-Risk Patient Identification.
  • Chart Retrieval >> Facilitates HIE and EHR Connectors.
  • Prospective Solutions>> Offers Pre-visit, Point of Care & Post-visit Review solutions.
  • Retrospective Solutions >> Offers Retrospective Review & Retrospective Audit Tools.
  • Data deidentification >> PHI & PII Deidentification specific to offshore coding operations.
  • Technology >> Industry’s leading Knowledge Graph infused cNLP- Neuro-Symbolic AI technology
  • Support >>Training as part of Payer & Provider Education pertaining to Compliance regulations.

Key Risk Adjustment Vendor Selection Criteria Checklist:

Expertise across risk adjustment processes:

What level of expertise does the risk adjustment vendor possess across various lines of business?
With CMS stressing more on prospective risk adjustment coding, health plans should

look for vendors who have the proven expertise, legancy in risk adjustment coding, a positive track record, and a progressive culture to adopt new methodologies for prospective and retrospective risk adjustment solutions. 

By recording the correct HCC codes during encounters, the solution provider not only ensures the expected accurate clinical workflow output but also enhances the overall process and prepares for an audit.

Experience and track record:

Look for vendors with a proven track record of success in healthcare risk adjustment. Experience working with healthcare payers, providers, or government agencies on risk adjustment initiatives is a valuable indicator of expertise and reliability.

Key aspects to consider Coding competency 

It goes without saying that any coding technology you adopt should make it easy for coders to review charts and enter proper HCC codes. But there’s more to the chart review experience than simply entering new HCCs. Some other factors to consider include:

  • Adds & Deletes: Is the vendor capable of conducting chart reviews using MEAT framework for both additions (supported HCCs) and deletions (unsupported HCCs)? Examining both aspects is crucial in today’s meticulously regulated environment.
  • Trace-mapping: Does the vendor offer a transparent audit trail for coding decisions?
    Is it clear which team member handled each chart, assisting with corrective measures if necessary?
  • Performance Monitoring: Does the platform offer metrics regarding coder accuracy
    and productivity to aid in making informed decisions regarding education and staffing?
  • Chase List Prioritization: Assess the vendor’s ability to prioritize and code high-risk conditions in patient charts, conduct retrospective chart reviews, submit accurate diagnosis data, and follow up on incomplete documentation. Effective prioritization is essential for healthcare risk adjustment to allocate resources efficiently to coding conditions having  the greatest impact on patient risk scores and address critical tasks promptly in order to maximize revenue while minimizing the risk of compliance issues or audit penalties.
  • Chart Retrieval: Evaluate the vendor’s chart retrieval process, which is vital as it encompasses securing medical records and documentation from healthcare providers for precise coding of patient diagnoses, a pivotal step in the risk adjustment process. Moreover, it gauges the efficiency of healthcare organizations’ compliance with regulatory standards, ensuring accurate diagnosis data submission to entities like the Centers for Medicare and Medicaid Services (CMS).
  • Insights and Analytics: How much value do the coded HCCs provide? Which chronic conditions are predominant among your member base? 
    Which providers exhibit a significant number of incorrectly coded HCCs during patient care
    Your technology vendor should assist you in addressing these critical questions about your program.
  • Cost-effectiveness and ROI:
    Compare the cost of the vendor’s solution against the potential return on investment (ROI) in terms of improved risk scores, revenue optimization, operational efficiency, and compliance with regard to regulatory requirements.
    The vendor’s risk adjustment audit and review solution needs to include advanced technology that uses AI to look back and forward. This will make sure that the code is compliant, lower the risk of RADV/OIG audits, increase overall productivity, and boost compliant ROI.
  • Accuracy and transparency:
    Assess the vendor’s methods for ensuring the accuracy and quality of risk adjustment data.
    This includes validating data extraction processes and inculcating quality assurance measures to minimize errors and discrepancies. In healthcare, OCR-readable clinical charts, also known as clinical data exchange services, make it easier to get multi-format, unstructured data from different EHR/EMR systems, speeding up chart processing. This ensures the extraction of accurate data at the source, preventing errors in subsequent workflow steps.
    If the quality of the solution fails to meet expectations, pricing also becomes irrelevant. This means the solution should not generate evidence-based coding predictions or overlook coding opportunities supported by documentation.
    Additionally, reviewing case studies and existing client relations provides candid insights into the quality and efficiency of the vendor’s services.
    The vendor solution must guarantee HCC coding accuracy by integrating MEAT framework, enabling automatic capture of HCC codes while also allowing human intervention. Furthermore, the solution must conduct prioritized audits, categorizing claims based on member severity and chronic cases. By optimizing chart review and integrating it with audit workflows, we enhance overall efficiency, resulting in increased productivity and system confidence.
  • Smart process execution and on-time deliverables:
    Evaluate the vendor’s capabilities in smart analytics and AI technology for accurately identifying and stratifying high-risk patient populations. Advanced analytics techniques can help improve risk score accuracy and optimize resource allocation.
    Evaluate whether vendors’ automated audit reviews of medical charts and HCC coding have undergone thorough testing with extensive real-world clinical and patient data. Computer-assisted coding (CAC) or clinical documentation improvement (CDI) systems customized for risk adjustment (RA) should have effectively deployed these solutions.
    These solutions should have effectively integrated industry-standard knowledge graph-powered clinical NLP technology.
  • Interoperability and Chart (Data Exchange) Processing:
    Ensure that the vendor’s solution supports interoperability standards and seamless data exchange with other healthcare systems (EHRs) and stakeholders. This includes compatibility with industry-standard chart data formats, APIs, and integration protocols.
  • Integration with Clinical Data Systems:
    Does the vendor understand your native process and workflow, and how can they work in tandem with your existing process?
    Ensure that the vendor’s solution seamlessly integrates with clinical data systems, electronic health records (EHRs), and other sources of patient health information to capture and analyze relevant clinical data for risk adjustment purposes.
    Vendors must understand and seamlessly integrate their solutions with their clients’ internal processes and workflows.

RAAPID’s clinical integration framework, with the support of our integration partner, enables the prospective pre-visit solution at the point of care.

Training and Support Services: Does your team receive training from the vendor as part of payer education?

Assess the vendor’s training and support offerings to ensure that users become tech-savvy and pro-process-oriented by providing sufficient training on the risk adjustment solution and ongoing support for troubleshooting, maintenance, and optimization.

Tracking performance metrics and vendor KPIs is essential to validating vendor deliverables for a successful risk adjustment program.

Therefore, as a support service, it is crucial that vendors offer a dependable reporting system, customizable to monitor specific coding quality parameters, and aligns with CMS audit and RADV-compliant requirements.

Privacy and Security Management: Verify to what extent the vendor’s risk adjustment solution complies with relevant regulatory requirements, such as CMS guidelines for risk adjustment, HIPAA regulations, and other industry standards for data privacy and security.

When checking for compliance, ask about user permissions and access controls based on organizational needs, as well as HIPAA/HITRUST/SOC2. These are must-haves on the part of vendors.

RAAPID prioritizes compliance, privacy, and risk management when handling PHI exposure. By masking PHI, regardless of whether individuals access data onshore or offshore, we elevate privacy, security, and compliance standards through the de-identification and masking of the eighteen (18) elements of PHI. This ensures that coders and auditors can effectively perform their tasks without any impact.

Scalability and Flexibility: Assess the scalability and flexibility of the vendor’s solution to accommodate growing data volumes, changing business requirements, and evolving regulatory landscapes. The solution should be able to scale up or adapt to new challenges without significant disruption.

Determine whether the vendor maintains a collaborative relationship with other third-party industry solution providers to implement specialized solutions that fall outside the vendor’s solution areas.

This ensures business continuity without causing delays or interrupting ongoing project activities.

Therefore, when evaluating new risk adjustment coding vendors, consider the limitations on chart processing in terms of size or batches, as well as scalability and performance reliability. Depending on the platform solution, some vendors may struggle with large batch processing or lack streaming capabilities. 

Receptiveness to changing project dynamics

How aptly does the vendor respond to changes being introduced to projects, For example, how promptly can the vendor onboard the team and get them aligned with the latest solution? Also, what approach does the vendor deploy to gather the necessary data and specifications as prerequisites for implementing the new solution?

Therefore, we need to understand the vendor’s ability to execute projects within timelines that align with the project’s evolving requirements, thereby ensuring seamless integration and optimal outcomes.

Final Thoughts

Every healthcare organization is different. Moreover, the vendor selection process can directly affect compliance and influence financial decisions. Your vendor should align with how you handle data and adapt to regulatory nuances in the interim and long term.

Finally, while most vendors offer clinical APIs, make sure yours is robust, flexible, scalable, and compliant with healthcare regulatory standards.


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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.