Tackling the challenges of bringing risk adjustment in-house

In Affinite Risk, Risk Adjustment by Marketing

Challenge #3: Execution

This is the third in our multi-part series on how health plans can overcome barriers to and reap the rewards of in-house risk adjustment. Part 1 covered process complexity; Part 2 looked at infrastructure.

Health plans often focus a majority of their risk adjustment resources on prospective and retrospective services designed to maximise HCC capture. The foundation of a solid risk adjustment program, however, is member and provider engagement. Plans receive significant value through patient assessment forms, in-home health assessments, and chart reviews. We discussed the challenges of conducting this work in Part 2 of this series. A foundational part of the strategy involves prospective information-gathering approaches that engage both members and the organizations providing care in order to collect, code, and report encounters as they happen. 

Risk-adjustment teams can ensure a member’s complete health status is documented each year by fulfilling two tasks:

  1. Ensuring that each member receives an annual in-home assessment or wellness visit with their physician

  2. Engaging providers to accurately diagnose, document, and report member health history

Member Outreach

Reminding members to schedule and keep their wellness visits is the first step to capturing and reporting encounters data. This is especially critical for members with chronic conditions who may visit specialists throughout the year but forgo an annual wellness visit. Specialists and emergency room doctors focus on specific health issues and  may not  document a member’s full health history. Health plans can take a few initiatives to spur members to visit their doctors but should take a thoughtful approach to minimize member abrasion due to over-engagement.

  1. Conduct member outreach directly or partner with a vendor to help schedule annual wellness visits. Members should be targeted using chronic condition suspecting..

  2. Utilize in-home health assessments. Deploy nurse practitioners to meet with members specifically to evaluate and diagnose potential chronic and acute conditions.

  3. Provide target lists to providers. Compile lists of patients you reasonably suspect may have HCCs and explain to clinics the financial benefits of bringing them in for diagnostics.

 Health plans typically conduct member outreach for a variety of reasons, including marketing, care management, care gap closure, and HCC recapture. Although coordinating member outreach across these activities is a challenge, doing so will minimize member abrasion. 

Provider Engagement

Provider engagement is the second foundational component of a successful risk adjustment program, and it begins before the member arrives at the doctor’s office. Coding education is a critical aspect of provider engagement that is often overlooked by health plans. Providers develop practice patterns over time, and these patterns lend themselves toward certain ways of coding and documenting patient health. Over time, these patterns may result in certain conditions that are under documented. Provider chronic condition capture prevalence should mirror market prevalence within a relatively small range. Plans should monitor prevalence at the provider level and engage providers who are consistently under-coding targeted chronic conditions.

Providers experience a high level of administration burden, which leads to physician burnout and may adversely affect the level of care a physician is able to provide., Plans  should take a thoughtful approach to provider engagement. Interactions should be designed to make the process as painless as possible to avoid increasing the burden placed on doctors. Best-in class provider engagement programs work with EMR administrators to design smart best practice alerts which integrate into a provider’s workflow to allow them to close risk adjustment gaps at the time of care.   

Strong data analysis can inform you plan on which conditions may be undercoded which members your suspecting program should target, and how best to engage patients and providers to earn the best ROI on your in-house risk adjustment initiatives. Contact Vital Data Technology to learn how.

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Peter Janelle
Director of Risk Adjustment Solutions

Peter Janelle has more than a decade of experience in health insurance, having worked both for payers and vendors. He has extensive knowledge of Medicare Advantage finance, including risk adjustment, stars, value-based arrangements, and healthcare economics. Before joining Vital Data Technology, Peter was in charge of risk adjustment operations at UCare, a regional Minnesota insurer with books of business in Medicaid, Medicare Advantage, and ACA.

Peter enjoys photography and outdoor adventure. An annual highlight is his annual winter camping trip to northern Minnesota. 

Peter holds a Master of Public Policy from the Humphrey School of Public Affairs at the University of Minnesota.

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