Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

The Risk Adjustment Rallying Cry

192 views

Published on

In healthcare there are a few programs that become so fundamental to an organization that they impact just about every team. In the most successful organizations we work with, risk adjustment is one of those uniting programs. Clearly, roles involved in capturing HCC codes used in risk adjustment factor scoring have a vested interest, but they are not alone.
In the finance department, knowing what reimbursement amounts to expect is critical to managing the business. Quality teams use many of the same tactics as their risk adjustment peers to close care gaps so aligning efforts creates multiple efficiencies. Patients also appreciate the coordinated approach of their care teams that minimizes office visits and maximizes the quality of care they receive.
Learn how organizations can use risk adjustment programs to rally teams across the organization to work towards their tangentially aligned goals more efficiently. In this presentation we have outlined how to design a program that meets the needs of risk adjustment, finance, and quality departments.

Published in: Healthcare
  • Be the first to comment

  • Be the first to like this

The Risk Adjustment Rallying Cry

  1. 1. |1 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved.©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. SCIO HEALTH ANALYTICS® The Risk Adjustment Rallying Cry November 30, 2017
  2. 2. |2 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. CHALLENGES COMMON TO RISK ADJUSTMENT Clinical Care Gaps Year End Crunch Tactics Incorrect Coding Missing HCCs Insufficient Staffing Measuring Impact of Programs Lack of Data Transparency Data Drop Off Collecting Data Risk Adjustment Factor Scores HEDIS, Stars & P4P Quality Scores
  3. 3. |3 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. LIMITATIONS OF A SINGLE-DEPARTMENT APPROACH Single Department = Single Focus Often Siloed / Minimal Collaboration Inability to Understand and/or Deliver Necessary Impact • Left Hand/Right Hand Risk Lack of Senior Leadership Support “Don’t Know What You Don’t Know” Hard to Foresee All Issues and/or Design Creative Solutions
  4. 4. |4 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. OTHER DEPARTMENTS WITH A SEAT AT THE TABLE
  5. 5. |5 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. DESCRIPTION • Responsible for measuring, monitoring and improving the clinical care and quality of service for members, and developing policies and procedures that reflect current standards of clinical practice. Strengths Challenges Opportunity in Risk Adjustment • Data collection for risk adjustment overlaps into quality reporting • Coming up with their own quality metrics based on a company-wide initiative. − Goal-setting (increase BCS with women by 10%) QUALITY DEPARTMENT • Experts at coordinating with providers • Retrospective chart reviews • Understanding data ‘asks’ of providers • Supporting multiple related needs (eg, HEDIS, Stars, and P4P) • Typically only involved after the fact • Limited impact on member behavior
  6. 6. |6 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. DESCRIPTION • Typically the team responsible promoting the company and driving sales • Frequently responsible for the “member experience” and everything that touches members • Roles may include Patient/Member satisfaction responsibilities • Satisfaction has a direct correlation to retaining patients/members Opportunity in Risk Adjustment • Influencers in patient behavior • Getting patients to be seen by their doctors MEMBER/PATIENT ENGAGEMENT DEPARTMENT • This is the “face” of the provider/plan to the member. • Not having access to current eligibility information limits their impact (eg, bad phone numbers / addresses) Strengths Challenges
  7. 7. |7 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. DESCRIPTION • Responsible for planning, organizing, auditing, accounting for and controlling the organization’s revenues. • Revenue is not a “dirty word” • It takes resources to deliver high quality and efficient care! Strengths Challenges Opportunity in Risk Adjustment • Understand impact of payment changes o Initial | Mid-year | Final • Work being done in RA has direct impact on dollars − Gatekeeper for investment decisions for your team FINANCE DEPARTMENT • Excel at managing expenses (a plus or minus for other departments) • Forecasting / insights into reliable numbers is key to sustaining a healthy organization
  8. 8. |8 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. DESCRIPTION • This department has many key roles, including: • Loading contracts and amendments into the claims system • Analyzing contracts to ensure claims are paid accurately Strengths Challenges Opportunity in Risk Adjustment • Transparency – line of sight into payment changes and forecasts CONTRACTING/PROVIDER RELATIONS DEPARTMENT • Can enhance relations with providers • Collaboration opportunities • Right size revenues A difficult relationship to manage: • Providers think they’re being underpaid • Payers think the providers being paid accurately – they’re the interface between providers and CMS but don’t participate in the patient visits.
  9. 9. |9 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. DESCRIPTION • Responsible for planning, operating and supporting the plan’s IT structure, enabling business users to carry out their roles efficiently, productively and securely. Strengths Challenges Opportunity in Risk Adjustment • Making sure all of this runs smoothly! TECHNOLOGY DEPARTMENT • These roles impact everything! − Incoming data − Internal processes − Outgoing data − Management of rejected data • Everything’s electronic and a single breakpoint can have a significant ripple effect downstream • Hard to know if something is wrong until it’s brought to their attention (data drop off points)
  10. 10. |10 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. THE MAKINGS OF A RISK ADJUSTMENT THANKSGIVING? Risk Adjustment Quality Patient Engagement FinanceContracting Technology
  11. 11. |11 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. DESIGNING AN EFFECTIVE PROGRAM
  12. 12. |12 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ASSESSING THE CURRENT STATE VIA DATA TRANSPARENCY Members with Gaps Provider-Specific Concerns Global Process Issues
  13. 13. |13 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. BALANCING RETROSPECTIVE AND PROSPECTIVE TACTICS Retrospective Prospective
  14. 14. |14 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. SETTING ACHIEVABLE GOALS • Develop goals alongside provider group leadership • Be “SMART”: Specific, Measurable, Assignable, Realistic, Time-Bound • Use two comparisons: year-over- year and against a benchmark • Mix quantitative-leaning goals (eg, RAF score increase) with qualitative-leaning goals (eg, attend risk adjustment education sessions)
  15. 15. |15 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. EXAMPLE ACHIEVABLE GOALS • Member Visits: Reduce percentage of members without an office visit to <20% in the next payment year. • Recapture Rate: Over the next year, 5% improvement in documenting previously reported HCCs for Dr. Smith. BEGINNER • Prevalence: 10% increase in members documented in 2 key HCCs (CHF and COPD). Led by risk adjustment department.INTERMEDIATE • RAPS & EDPS: Attain RAPS/EDPS HCC capture discrepancy of within 5% by the final EDPS submission date. Led by the IT department ADVANCED
  16. 16. |16 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. THE THREE “RIGHTS” Engaging the RIGHT PERSON (member or provider) with the RIGHT INFORMATION at the RIGHT TIME(S) Before Visit During Visit After Visit Challenges Member Not Visiting PCP PCP Does Not Diagnose and Document Member Conditions Coding / Billing Process Failures Documentation Not Submitted to CMS Solutions Member Suspect Lists Patient Engagement In Home Visits Provider Education Sessions Incentivization Visit Support Tools Chart Review Data Flow Analysis and Quality Initiatives
  17. 17. |17 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. TAKING STOCK OF NEW MEMBERS/PATIENTS Before Visit
  18. 18. |18 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. CLOSING DOCUMENTATION GAPS During Visit Chronic Conditions Previously Documented Now Missing For This Member
  19. 19. |19 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. QUANTIFYING DOCUMENTATION GAPS After Visit Chronic Condition Documentation Gaps and Their Financial Impact
  20. 20. |20 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. DOCUMENTING DIAGNOSIS CODES After Visit
  21. 21. |21 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. EXAMPLE DIVISION OF LABOR Suspecting Chart Review Member Engagement Provider Engagement Data Handoff Data Submission to CMS Confirmation of RAF Score Confirmation of Quality Measure Closure Payment Sharing Governance
  22. 22. |22 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. MEASURING PROGRESS An Important Part of a Well-Run Risk Adjustment Program is Measuring Results Measure ROI Communicate Top to Bottom Celebrate Success Set Year-end and Interim Goals Create a Balanced Scorecard Watch Results and Trends Over Time Special Recognition
  23. 23. |23 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. SCALING: SMALL VS. MEDIUM VS. LARGE ORGANIZATIONS • Cross functional team • Solicit feedback, internal/external • Develop relationships with providers • Electronic reports • Deliver actionable reporting, paper based • Monthly/Quarterly Small Medium Large
  24. 24. |24 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. PAYER/PROVIDER COLLABORATION
  25. 25. |25 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. START BY UNDERSTANDING THE PARTNER YOU WORK WITH Use of Technology Risk Adjustment Sophistication Human Capital
  26. 26. |26 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. SUPPORTING A RANGE OF PLANS & PROVIDERS Sophisticated processes in place to optimize outcomesNewer to risk bearing contracts 5 Star Organization Sharing reports and suspect lists in the right format Outsourced patient and provider engagement for gap closure Risk Adjustment 101 – Provider in-service and education Portal for CMS and claims data transparency Contract 1 Contract 2 Contract 3 One Platform to Manage Medicare Risk Adjustment Flexibility to Engage Providers in Various Stages of the Risk-Bearing Readiness Continuum
  27. 27. |27 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. ORGANIZATION PROFILE 65,000+ Member Medicare Advantage Health Plan Goal Solution • Optimize revenue and quality by collaborating with providers to: − Identify members with chronic gaps in care − Identify low performing providers who may need additional risk adjustment support and education − Deliver actionable information to provider groups in a consistent format • Developed a three-pronged approach based on the provider sophistication/ volume: − High volume providers: Full access to risk adjustment analytics − Low volume providers: Share health assessment tool reports − Outlier providers: Risk Adjustment 101 education Results • Annual revenue potential of $24 million per month • Successfully closed 38% of gaps for members with chronic conditions in the first year. PARTNERING WITH PROVIDERS ACROSS A SPECTRUM
  28. 28. |28 ©2017 SCIOInspire, Corp. d/b/a SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. Contact us Corporate Headquarters SCIO Health Analytics® 433 South Main St., Suite 203 West Hartford, CT 06110 info@sciohealthanalytics.com www.sciohealthanalytics.com

×