These tech-led retrospective approaches can help health plans ensure the data they submit is complete and accurate—without leading to further provider abrasion.

As we head into 2022 still under the cloud of the pandemic, health plans remain under continued pressure to maximize savings and improve patient outcomes. This is a tall order, considering the fact health care spending and regulatory oversight are on the rise and risk scores are on the declinenot to mention the transition from RAPS to 100 percent EDPS. With all of these factors in mind, it has become more important than ever for health plans to submit complete and accurate health status information to the Centers for Medicare & Medicaid Services (CMS).

While the deadline extension for 2020 dates of service to August 2022 certainly provides some relief for health plans, typical risk adjustment strategies such as medical record retrieval often lead to provider abrasion. As the most recent COVID surge threatens to overwhelm health care facilities across the country, there is no such reprieve on the horizon for primary care providers.

So, how can health plans take advantage of the submission deadline extension without putting pressure on already overburdened providers? Here are three tech-led strategies to consider.

1. Bolster your analytics capabilities

A risk adjustment program is only as effective as the data at its disposal. That’s why it is critical to ensure data is as accurate as possible before it is ingested by natural language processing (NLP) software or processed to calculate risk scores. A strong risk adjustment analytics workflow tool should be able to quickly and accurately streamline volumes of data and provide quality assurance. This tool should verify the accuracy and integrity of patient population data, highlight suspected member health conditions that need to be assessed, and offer population management stratifications. By first understanding where your opportunities are, you can then know where to implement additional strategies.

2. Optimize your second level review with advanced NLP

Coding accuracy is critical to calculating risk adjustment and budgeting for future patient care. With the submission deadline extension, plans should use this extra time to implement an NLP-targeted second level review to increase coding accuracy. It’s important to find a tool that has been trained on a high volume (and quality) of medical records so it can learn and improve over time. But NLP alone is not enough. Any tool should work alongside expert human coders to evaluate the MEAT of a code and substantiate documentation. This will help improve coding submission accuracy, uncover missed RAF opportunities, and match services to member needs. It’s important to remember that this process is not just about adding codes, but also ‘looking both ways’ to remove unsubstantiated codes.

3. Reduce data leakage in the RAPS to EDPS transition

While this is the last year plans must submit both RAPS and EDPS, it is still critical that they accurately and completely reconcile claims in both systems—otherwise, they will see adverse effects on their risk scores. While RAPS requires fewer than 10 data fields, EDPS requires 150, creating more opportunities for errors or missing data. However, an intelligent data management solution can automate and streamline reconciliation of RAPS and EDPS to ensure the complete and accurate submission of encounter data. Reconciling claims in both systems can also help identify if all supplemental data has been accepted, mitigating the risk of paying for something that did not result in an improved outcome.

What I’m doing right now works for me. Why change anything?

One of the many lessons the pandemic has taught us is the need to be proactive. Beyond the challenges of COVID and other regulatory and industry factors at play, it’s important to keep in mind that CMS recalculates risk scores every year in order to maintain an average of 1.0. Coding intensity factors and normalization are also applied to account for risk adjustment coding practices and annual expected changes. However, by employing these tech-led retrospective approaches, health plans can help ensure the data they are submitting is complete and accurate—without leading to further provider abrasion.

RISE National 2022

Episource arms clients with data, tools, and insights to navigate the chaos of the health care system. To learn more, join Vinitha Ramnathan, senior vice president of product, Episource, at RISE National 2022, March 7-9, live at Gaylord Opryland in Nashville, Tenn. for a presentation on how to improve patient outcomes and plan performance using a platform approach. Click here for the full agenda, roster of speakers, health and safety protocols, and how to register.


About the authors

Meleah Bridgeford

As the senior director of risk adjustment analytics at Episource, Bridgeford plays a vital role in overseeing the company's submission solution, epiEncounter. She is responsible for the development of new analytic platforms for health care exchange programs as well as working with existing platforms for Medicare risk adjustment in order to meet the growing needs of clients within a complex industry. She has over 10 years of experience within health care organizations as well as vendor/consultant organizations.



Susan Richards

As the director of risk adjustment and coding education at Episource, Richards is responsible for developing and managing the integrated programs that support end-to-end retrospective and prospective risk adjustment services, including provider education, HEDIS, and clinical documentation integrity. Nationally recognized as a leader in value-based care, Susan has more than 20 years of leadership experience in the health care industry. She has served as an active steering committee member for coding organizations such as AAPC and AHIMA. She has a BS in human biology as well as a doctorate in chiropractic from Cleveland Chiropractic College.