Quick Hits for September Sweeps

Unfortunately, Risk Adjustment does not have the luxury of taking the summer off. As CMS continues to stress the criticality of submitting complete, timely and accurate data to support plan payments related to Risk Adjustment, health plans must have year-round processes in place to ensure compliance as well as accurate payment from the government.

As premiums continue to be reduced, health plans and capitated medical groups must have strategies in place to ensure an accurate Risk Adjustment Factor (RAF) score, meaning you must not only recapture your members’ persistent conditions, but find new clinical conditions as they appear. Sounds easy? Not quite. As we’ve seen the processes, programs and requirements are daunting and difficult to juggle. Our advice: leverage existing analytics and data to drive efforts for Risk Adjustment and the looming September deadline.

Items to focus on:

1. Specialists/Providers– What is your strategy to engage specialists? Collaborative partnerships between health plans and providers will ensure optimum performance outcomes for revenue, medical management, and quality. Assess the root cause and go right to the source. By following the initial diagnosis, you will be able to prioritize your outreach by disease prevalence.
2. Pharmacy– Mine your pharmacy data. If this data reveals prescriptions for medications specifically prescribed to treat risk adjustable diagnoses and the patients are consistently filling medication — yet there hasn’t been a diagnosis submitted through a claim- a new variable for prioritizing provider or member outreach has been created. Try looking at your patients that meet the criteria for Medication Therapy Management (MTM). Not only is MTM a strong tool for managing costs, improving outcomes, and positively impacting your Star Ratings, the program can support your efforts to prioritize initiatives for Risk Adjustment.
3. Clinical Quality and HEDIS– Partner and coordinate with your Healthcare Effectiveness and Data Information Set (HEDIS) teams. Leverage the information and clinical data retrieved and reported for HEDIS measures to identify members with risk adjustable diagnoses. If your plan uses a HEDIS vendor, make sure that you are reviewing their most recent audited HEDIS reports. If a claim or claims do not exist, but patients have been pulled into HEDIS measures through chart reviews, create a chase list to reconcile that data and then assign the most appropriate patient and provider intervention.
4. Manpower — Are you lacking the technology to aggregate and create your target and suspecting lists? If interim staffing is what you need, Gorman Health Group (GHG) can enhance your team with our own, providing knowledgeable, effective assistance and an eye for detail from processors and analysts with decades of experience.
5. In- Home Assessments — Adopt a core set of components and best practices for In-Home Assessments, prioritization and timing of these assessments is key. Track subsequently provided care: In CY 2015, The Centers for Medicare & Medicaid Services (CMS) will track and analyze care provision following in-home visits. If you are mining your data and notice a beneficiary has not been to the doctor in some time, take initiative and facilitate an in-home assessment. These encounters can also be leveraged to close HEDIS gaps and close the care coordination loop, avoiding ER visits or unnecessary trips to Urgent Care facilities.
6. Vendors – Convene with your vendor partners to coordinate strategies. Include the Case Management team, Utilization Management team, and Provider Network team in your strategy discussions. All departments need to be working together to understand what visits are coming up in your provider network and why — who better than the teams who are on the front lines?  Whether you rely on multiple vendors or a largely internal team, we can help you streamline the execution of your risk adjustment approach, and maximize your analytic strategy to ensure you’re keeping pace with CMS expectations in both compliance and healthcare outcomes.

It’s all about prioritizing. Mining the data to leverage the analytics you already have is a good way to start.

Get it right the first time. Managing the operations of your risk adjustment function is no easy task. The integrity of your data impacts virtually every other department in your organization – especially Finance, Quality, and Care Management. It’s important to examine the data and submit it correctly the first time to guard against data inaccuracies, errors as well as to allow for appropriate reimbursement.

GHG supports our clients in evaluating the efficiency, compliance, and strategic value of their risk adjustment programs from start to finish, and helps ensure the procedures for capturing, processing, and submitting risk adjustment data to CMS are accurate, timely, and complete.

Whatever your organization decides to do, your strategy should be targeted, prioritized, and have a clear call to action. You have time and options. Contact us today to discuss them.

Resources

Gorman Health Group (GHG) announced its new vision for maximizing healthcare analytics and optimizing risk adjustment programs. Read the full press release >>