Webinar Recap: “Five Risk Adjustment Myths Impacting Your Program” (Part 2 of 3)

June 7, 2017 Marissa Lawson

You’re well aware that the successful execution of your risk adjustment strategy is more complex than it might seem. And in our first installment of this three-part series recapping our recent webinar, we discussed that relying too much on your EMR’s problem list as the best or only source for risk adjustable conditions is one of the factors that complicates performance. 

As we have discovered through our experience in over 30 health care markets, using your EMR alone will not capture all risk adjustable patients – it takes a variety of data sources to establish the full picture, and move forward from playing catch up with retrospective reviews. In fact, we believe that the future of risk adjustment is prospective, and that’s just the tip of the iceberg. 

Continuing to pull from the expertise of Mike Lee, Evolent’s risk adjustment Regional General Manager, and Dr. David Koehler, Deaconess Health System market medical director and practicing family physician, let’s dig in on the next two myths and their attendant realities. 

Myth #2: Retrospective chart reviews are sufficient for risk adjustment. 

But the reality is… Retrospective chart reviews are really more of a revenue cycle cleanup activity that solves immediate gaps of information and documentation codes. It is great for “instant gratification” but leaves a lot on the table, and, as Mike said, simply doesn’t drive improvement over the long haul. To make the most impact, investment in a prospective risk adjustment program is highly recommended. Prospective risk adjustment goes beyond simply rectifying past gaps in HCC coding, and actually brings those “misses” into the prospective physician workflow. 

The advantages of prospective risk adjustment are threefold: it can expose the physician to additional diagnoses that a patient may have; which in turn then increases the clinical insight and informs care management activities allowing for better and more targeted future care; and overall drives more complete and accurate documentation. 

Dr. Koehler chimed in with the physician’s perspective – prospective risk adjustment goes beyond a “fill in the blanks” mentality, and actually provides point of care physicians with excellent diagnoses codes and a complete burden of illness represented in the system, which allows providers to better assist the sick patients they see. 

In order to make the most of having both retrospective and prospective risk adjustment programs, they need to actually talk to each other and work together. This is another point where it’s easy to get tripped up – often, providers have two completely separate tools for each respective risk adjustment program. Instead, you want a single infrastructure that supports your entire network from a technology and services standpoint. 

Myth #3: One size workflow fits all.

But the reality is...  prospective risk adjustment is not a cookie cutter activity, and physician engagement is one of the ultimate keys to success. In any given system, consider how many physicians are typically affiliated vs. directly employed, and what that means for their participation in your risk adjustment strategy. It is much easier to engage fully employed physicians than those only affiliated with your plan, so simply assuming that your entire network will comply with your strategy will contribute to unsuccessful execution. Depending on the setting and situation, providers have different workflows and processes inherent in their day-to-day, so it is critical that your strategy is flexible enough to engage all providers in all locations. 

For your employed physicians working on one of the larger, more common EMRs, the reality is they probably don’t navigate that EMR the same exact way. Despite these differences, you need to ensure participation and compliance with your campaign. EMR integration can pull data from a wide variety of sources and push critical insights and workflow to your physicians within the host EMR. This allows your physicians to quickly access patient risk, see open care gaps and document risk appropriately. Beyond your employed physicians, your affiliated physicians (which make up ~60% of our partners’ collective networks) are likely not using your host EMR, or even the same one – not to mention the physicians that Dr. Koehler knows who are still working off of paper! To mitigate this issue, a web-based application that can be used across your network to properly document risk adjustment conditions is extremely helpful. Consolidating information so that physicians are only receiving one patient assessment form across all payers makes it easier to use and fill out. 

In order for risk adjustment best practices to truly take hold, it is essential that there is more than one way to view and address suspect conditions to support the diversity of the physician network and the delivery channels used by the providers. Beyond this, developing and sustaining a rigorous communication and training program is necessary to build upon your progress and truly obtain the buy-in of the physicians charged with implementing that strategy.

Building an infrastructure that fulfills all of these criteria will likely require help. Seek out a partner who has both technology and physician engagement chops, and the experience to understand that an effective governance strategy is needed to tie it all together. 

In our next and final installment, we’ll dive into this notion of why the expertise of the team around you is the most critical piece of the puzzle – from initial physician engagement to ongoing compliance and execution. The experience of those who have been there before truly makes all the difference both in terms of your patients’ wellbeing and the accurate capture of diagnoses. 

In the meantime, feel free to check out the webinar recording or contact us for an in-depth discussion on what your strategy is missing.

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