In this paper, Health Fidelity outlines the concept of a 360-Degree View of Risk Adjustment and articulates why it’s vital to succeed in today’s value-driven care environment. Additionally, organization’s can also learn the evaluation framework required to assess your readiness to adopt the 360-Degree View.
In order to make downstream risk adjustment modernization efforts as effective as possible, organizations need to ensure they have the appropriate structure, goals, and incentives in place. In this next chapter, Health Fidelity examines the operational infrastructure and leadership activities required to set a foundation for performance improvements.
In the third installment, Health Fidelity assesses accessibility to data – clinical, claims, and beyond – along with performance transparency; both are critical components required to achieve a culture of continuous improvement across the organization.
With operational precursors complete, this paper turns to core risk adjustment activities, beginning with prospective review. Coordinated efforts in provider engagement, member outreach, and data-driven prioritization will be key to optimizing prospective review results.
Providers are key partners for many payer-led initiatives, including but not limited to risk adjustment. In order to enhance both quality of care and financial outcomes, organizations should make sure the appropriate alignment, incentives, education, and tools are in place to increase providers’ engagement with these initiatives.
Organizations should enable access to the fullest breadth of up-to-date clinical data from medical records. Many areas within the organization will benefit from increased access to data – not just risk adjustment. The key is to invest in scalable solutions that enable multiple departments to leverage a common set of records and reduce redundant chart retrievals that are extremely costly.
In this paper, Health Fidelity reviews technology-enabled workflows that allow risk conditions to be captured more accurately and efficiently. When many of the tedious manual processes are augmented with technology, coders can better utilize their skills to focus on accurate coding of diagnoses.
n the final installment, Health Fidelity presents modern approaches to compliance that ensure maximal adherence to regulations and protect against possible penalties. Small enhancements with risk adjustment processes can help to ensure proper validation of codes and better audit preparedness.
With the mandate to “do more with less,” Providence Health Plan turned to Natural Language Processing (NLP) technology to address their risk adjustment challenges. In October, Providence Director of Coding Compliance – Rebecca Welling – shared how her decision to equip her coding team with access to all available information via NLP allowed for better efficiency, increased risk capture, and reduced audit risk.
In 2014, UPMC Health Plan, as part of a leadership-sponsored strategic initiative, implemented HCC Scout to help increase accurate RAF capture in compliance with CMS Risk Adjustment guidelines while improving overall coding efficiency. The health plan, which was already running sophisticated risk adjustment operations, saw a remarkable return on investment with a study conducted on PY2012 members.