In our first and second installment of this three-part blog series recapping our risk adjustment webinar, we’ve discussed why risk adjustment is a deceptively difficult strategy to execute properly. Without experience in operationalizing risk adjustment campaigns, it’s all too easy to make assumptions regarding the first three myths that we covered: that using your EMR’s problem list is the best source for risk adjustable conditions, that retrospective chart reviews are sufficient, or that one size workflow fits all.
However, based on our experiences across multiple markets, we have identified the particular nuances that challenge each assumption or myth that require additional planning and consideration in order for your strategy to be successful. As presenter Mike Lee, Regional General Manager of Risk Adjustment stated, risk adjustment is a “calendar-year phenomenon.” In the eyes of CMS, whatever condition you went to bed with on New Year’s Eve, you don’t have any more upon waking up on January 1. Letting essential health data that you’re already aware of slip through the cracks can have a devastating effect, which is why monitoring your infrastructure and processes rigorously, consistently, and in a manner that is compliant with CMS rules and regulations is so important.
Read on for the last two myths and the realities we’ve discovered.
Myth #4: Risk adjustment compliance: set it and forget it?
But the reality is… risk adjustment has a lot of regulatory focus due to constantly evolving CMS requirements, the changing landscape of relevant technologies and new populations using risk adjustment. This guarantees continued regulatory attention and the need for adaptation and compliance by market participants. The level of scrutiny involved can trip up your organization if you aren’t meticulous about compliance. As you look at vendors for both the retrospective and prospective processes of your risk adjustment campaign, be an informed customer and ask about their approach to compliance. It is crucial to invest in the right software and infrastructure that can reduce errors.
But only relying on your vendor or software can be dangerous. Align with best practices by conducting mapping exercises to identify where gaps could occur before it’s too late. Build in governance checks and balances, and hold mock RADV audits to ensure mistakes are that much harder to make. And of course, you must incorporate vigilant awareness for the importance of compliance into all training, underscoring the need for evidence to substantiate submitted diagnoses.
Myth #5: Technology is the answer to solve risk adjustment.
But the reality is… you can have the greatest tech in the world, but if your physicians are not engaged and the operations are clunky, you won’t solve for anything. To be successful, you need to build an accountable operational model around your technology that ensures your campaign is running smoothly all year round. True accountability entails establishing benchmarks and metrics from the outset so that you can track and measure performance, and course-correct where necessary.
Additionally, your people -- the backbone of any organization – must buy into the organization’s goals and the strategy for how to achieve them. An experienced, engaged staff who can manage the tactics, mitigate any risks and deliver results in a streamlined fashion is the linchpin of your campaign’s execution. Ideally, the synergy of your operational model, technology and engaged staff drives a virtuous cycle of improvement that enables year-over-year process efficiencies and appropriate capture of your patient’s burden of illness.
The biggest overall takeaway of the webinar? As Mike stated, risk adjustment is a critical component of your value-based clinical and financial strategy – “but there is no silver bullet.” Instead, a successful strategy will include the right technology and infrastructure, and most importantly, an experienced staff that feels engaged in its success to execute upon that strategy.