Partnering for success in 3 critical areas of risk adjustment

Health plans that participate in risk adjustment understand the importance of accurate and timely data on the health status of members. However, risk adjustment involves multiple steps and challenges, such as identifying the most relevant members to target for chart review, retrieving medical records from various sources and formats, and coding the diagnoses according to complex and evolving guidelines—all while ensuring compliance with industry regulations.

In a recent Cotiviti webinar, our experts shared best practices for health plans to perform these tasks efficiently and accurately, while utilizing the right technologies and partners to support them throughout the risk adjustment cycle. Here, we discuss how health plans can achieve better risk adjustment results by partnering with experts in three key areas, including medical record retrieval, interoperability, and coding.

Improving medical record retrieval results

Medical record retrieval is one of the most challenging aspects of risk adjustment as health plans must overcome low provider response rates, high costs, long turnaround times, and incomplete or inaccurate data. To improve medical record retrieval results, health plans can benefit from working with a partner that can deliver the following capabilities:

• A large and diverse network of digital connections with providers, health systems, health information exchanges, and national networks that enable faster and more efficient access to records in electronic formats
• A multi-channel approach that combines traditional approaches such as fax and copy services to overcome any digital gaps and drive results
• A dedicated process that optimizes and consolidates requests, reducing provider burden and increasing provider participation, and that uses historical data and analytics to improve success
• A scalable and flexible infrastructure that can handle high volumes of requests, adapt to changing timelines and requirements, and integrate with the health plan's systems and workflows

By working with a partner that has these capabilities, health plans can enhance the efficiency, quality, and cost-effectiveness of their medical record retrieval results.

Improving interoperability

Healthcare interoperability is the ability of different systems and organizations to exchange and use digital health data in a meaningful way. But due to technical, operational, and legal complexities, interoperability is not easy to achieve, and data exchanges are often met with challenges. Health plans encounter different data formats, standards, and protocols, such as HL7, C-CDA, and FHIR, and must ensure that they are compatible and up-to-date. They also need to establish data use agreements with partners and providers to ensure that the data is used for permissible purposes and protected according to privacy and security regulations. Moreover, the data they acquire should be high-quality, complete, and accurate.

The right partnerships can enable health plans to improve interoperability with the following capabilities:

• A deep knowledge of the technical and regulatory landscape and how it impacts payers and their risk adjustment programs, including the latest trends and changes in data standards, protocols, and rules
• A comprehensive network of data partners, such as health information exchanges, national networks, data aggregators, or EHR vendors, that can provide access to a wide range of data sources and use cases, such as healthcare payment and operations, quality measurement, or patient access
• A robust and reliable data acquisition and management process that ensures meaningful data exchange and ingestion, using the appropriate methods, protocols, and implementation guides for each use case, and applying quality checks and validations along the way
• A sophisticated and flexible data normalization and mapping process that ensures semantic interoperability and commonality among terms, codes, and concepts
• A seamless and secure data integration and delivery process that ensures the data is stored, enabled, and shared back with the health plan and other stakeholders in a way that meets their needs and workflows, and that complies with privacy and security regulations

By leveraging the power of digital data for their risk adjustment programs, health plans can improve their effectiveness and successfully adapt to changing regulations.

Improving coding accuracy

Coding accuracy is among the most critical aspects of the risk adjustment process and can have a significant impact on the premium accuracy and quality outcomes of a health plan—but it’s also complex, involving human and technical factors and challenges.

To improve coding accuracy, search for a partner that displays proficiency in the following categories:

• Certified and experienced coders, who have the expertise and credentials to code for different risk adjustment programs, such as Medicare Advantage, Affordable Care Act, or Medicaid, and who are trained and updated on the latest coding guidelines and industry best practices
• Strong analytics and technology, including natural language processing (NLP) and artificial intelligence (AI) capabilities to enhance the coding process and improve productivity
• A strong quality assurance and training program that continuously monitors and evaluates performance, using audits, feedback, quizzes, or benchmark charts, and that provides tailored and timely education and improvement opportunities
• The capacity, scalability, and flexibility to handle a large volume and seasonality of work, including an adaptable strategy to fit changing timelines and requirements

Optimize risk adjustment results and coding accuracy by choosing a partner that aligns with organizational values and employs a diverse and rigorous set of standards to meet your defined goals.

Risk adjustment is a critical process for health plans that participate in risk-based contracts, as it affects their long-term sustainability. However, it is also a complex and challenging process that requires the right technologies and partners to support health plans throughout the year. By partnering with experts in medical record retrieval, interoperability, and coding, health plans can achieve better risk adjustment results by enhancing their efficiency, quality, and cost-effectiveness.