As you pack your bags to head to Scottsdale for the RISE West Summit, there’s no doubt that compliance will be a key topic addressed by many. With so many policy updates, overall uncertainty in the health care industry, and the recent focus drawn to risk adjustment from the UnitedHealth vs. Swoben lawsuit, all risk-bearing organizations are looking to elevate their compliance posture but often with the same or fewer resources. The pressure to do more with less is a universal condition, it seems.
If compliance is a key priority for your organization, here are the areas we recommend you explore during your RISE trip:
- Focus around audits is intensifying.
On the heels of the S. Department of Justice (DOJ) joining the False Claims Act lawsuit, the pressure is mounting to eliminate fraud and overpayments across Medicare, Medicaid and ACA plans, with many expecting an increase in audit activity. Responding to audits is time-consuming and costly, requiring organizations to scramble to find, re-request, and re-review medical records, compromising their ongoing risk adjustment operations in the meantime. Conversations on identifying strategies and technologies to streamline audit preparedness will be prolific at RISE. Look for tactics and solutions that can help you manage a rigorous quality assurance process and centralize documentation for easy records retrieval during an audit.
- NLP and technology-enabled solutions will dramatically reduce compliance risk.
Validating all diagnosis codes on claims (i.e., a two-way review) is an arduous and time-consuming process. And, since an estimated 80-90% of risk adjusted codes are submitted directly by providers, focusing only on your coder compliance ignores the biggest risk of all—providers who are unfamiliar with coding requirements. At RISE, look for new tools that leverage natural language processing (NLP) to drastically reduce the number of unsubstantiated codes submitted. With a streamlined workflow that automatically flags questionable codes, an NLP-powered compliance solution allows risk adjustment professionals and internal auditors to quickly and accurately conduct two-way reviews, correct previously-submitted codes, and identify educational gaps across the provider network.
- Data-driven tools can help to identify gaps and educate for sustainable improvement.
In addition to audit-preparedness policies and procedures, implementing efficient data analytics tools to flag conditions, providers, and members with high audit risk is critical. By systematically analyzing historical data to spot systematic errors and and benchmark coding patterns, these tools can help identify targeted areas for further education and training. At RISE, look for insight on tools that allow you to collect and leverage coder feedback to educate providers in how to more accurately document and code to reduce the number of risk conditions that slip through the cracks.
The compliance landscape can be overwhelming, but learning all you can at RISE is a great place to start. If you’re looking for one-on-one advice, insight and answers, stop by and see us at Booth #20 to learn more about our HF360 Risk Adjustment solutions that help risk-bearing organizations find more, spend less, and take control of your risk adjustment operations.
We look forward to seeing you in beautiful Scottsdale!
For any questions on how Health Fidelity can help reduce your compliance risk, contact us.