Operational Strategies and Technology for Risk Adjustment in Federally Sponsored Healthcare

ZeOmega’s blog series on risk adjustment looks at where we’ve been, what we’re facing today, what’s on the horizon, and how to best prepare. Over the remaining blogs, our ZeOmega risk adjustment solution experts will provide a forecast of regulatory changes and guidance on ensuring risk payment accuracy in both business and clinical operations.

The topics we’ll be covering in this series are:

1. Brief overview and history of the Risk Adjustment (RA) program.
2. The results of RA policy and how it’s led to gamification of chronic condition coding.
3. The value of risk-adjusted data across your organization.
4. How overpayments in risk adjustment threaten the Medicare Trust Fund solvency.
5. Recent federal actions and the next steps to control overpayments.
6. Strategy and platform pivots required to move forward successfully in risk adjustment.
7. ZeOmega’s expert tips and how the Jiva Risk Adjustment Navigator meets the evolving RA

Achieving maximum success in risk adjustment while maintaining compliance is crucial for payers and providers participating in federally sponsored healthcare programs. Risk adjustment plays a vital role in accurately predicting and reimbursing healthcare costs based on patient acuity, ensuring fair compensation, and equitable care delivery. To effectively navigate the complexities of risk adjustment, a combination of operational strategies and technology is essential.

Implementation of compliant processes and tools is the responsibility of payers that will help to maintain the stability of these safety net programs for years to come. This blog provides a comprehensive list of key operational strategies and technological solutions that can empower payers and providers to optimize risk adjustment outcomes while adhering to compliance requirements.

I. Operational Strategies for Risk Adjustment:

Data Collection and Documentation:

• Implement robust systems to capture comprehensive patient data, including diagnoses, procedures, and medications.
• Train healthcare providers on accurate and thorough documentation to ensure proper coding and capture of relevant clinical information.
• Establish processes for regular review and validation of data to minimize errors and discrepancies.

Coding Accuracy:

• Employ certified coders who are knowledgeable about risk adjustment methodologies and coding guidelines.
• Conduct regular coding audits to identify and rectify coding errors or omissions.
• Offer coding education and feedback to providers to improve accuracy and completeness of coding.

Provider Engagement and Collaboration:

• Foster strong relationships with healthcare providers to encourage active participation in risk adjustment efforts.
• Provide education and training to providers about risk adjustment, including its impact on reimbursement and patient care
• Develop collaborative workflows that facilitate efficient communication and feedback between payers and providers.

Analytics and Reporting:

• Utilize advanced analytics tools to analyze and interpret risk adjustment data, identify patterns, and evaluate performance.
• Generate comprehensive reports and dashboards to track key performance indicators, identify areas for improvement, and monitor compliance.
• Establish regular feedback loops with providers to discuss performance, address gaps, and develop improvement plans.

Compliance and Auditing:

• Develop robust compliance programs to ensure adherence to federal regulations and guidelines.
• Conduct regular internal mock- RADV audits to identify compliance gaps and implement corrective actions.
• Stay updated with changes in regulations and make necessary adjustments to operational processes and documentation practices.
• Be cautious when including chart review and HRA data and take additional steps to ensure clinical evidence exists for suspected conditions.

II. Technology for Risk Adjustment:

Electronic Health Record (EHR) Systems:

• Implement EHR systems that support comprehensive documentation and coding capabilities.
• Ensure interoperability between EHR systems and other data sources to facilitate data sharing and integration.

Clinical Decision Support (CDS) Tools:

• Deploy CDS tools that provide real-time guidance to clinicians on coding and documentation requirements.
• Integrate risk adjustment models and algorithms into CDS tools to assist providers in identifying and capturing relevant diagnoses.

Claims and Coding Software:

• Utilize claims processing software that incorporates risk adjustment logic to accurately calculate risk scores and reimbursement.
• Implement coding software that assists coders in accurate code selection and documentation improvement.

Data Analytics and Reporting Solutions:

• Invest in advanced analytics platforms capable of handling large volumes of data and performing risk adjustment calculations.
• Utilize data visualization tools to present risk adjustment insights in a user-friendly and actionable manner.
• Reconcile diagnosis data year-over-year to ensure that chronic conditions are captured and accepted by CMS.
• Analyze rejection codes address underlying cause of rejections and resubmit accurate data.

Interoperability and Health Information Exchange (HIE):

• Establish robust HIE capabilities to facilitate secure and timely exchange of patient data between payers and providers.
• Enable interoperability between different health IT systems to ensure seamless data sharing and continuity of care.

By implementing these operational strategies and leveraging appropriate technologies, payers and providers can enhance their risk adjustment efforts in federally sponsored healthcare. These approaches help optimize revenue, improve patient outcomes, and maintain compliance with regulations, ultimately leading to maximum success in risk adjustment.

Ask us how The Risk Adjustment Navigator can add to the value of Jiva, ZeOmega’s Healthcare Enterprise Management Platform.

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