Outsourcing risk adjustment coding to a vendor presents a multitude of challenges for Medicare Advantage Organizations (MAOs). One of the most significant pain points is the lack of visibility into the vendor’s progress and performance throughout the project. Typically, MAOs are left in the dark until the project is completed, making it difficult to monitor coding quality, timeliness, and adherence to contractual obligations in real time. Additionally, there is a risk of misaligned incentives, where vendors may prioritize volume over precision, potentially leading to financial discrepancies and regulatory penalties. Effective vendor oversight is crucial in mitigating these risks, ensuring that MAO’s can confidently rely on external partners to meet their risk adjustment program objectives while maintaining the highest standards of compliance and efficiency.
Centralized operations: The ideal solution
Bringing vendor coding in-house where your internal and vendor teams are working together within one software tool placing the MAO in the driver’s seat. This “command center” approach provides MAOs greater visibility and control over vendor activities. Centralizing operations fosters real-time communication and collaboration, allowing immediate identification and resolution of discrepancies. A single, unified platform ensures that MAOs can closely monitor the quality and accuracy of coding, aligning vendor processes with regulatory requirements and organizational standards.
Four key benefits of creating a command center
1. Improved coding quality
- Accuracy and compliance: MAO’s must comply with CMS regulations. Accurate risk adjustment coding is vital for proper reimbursement and resource allocation. Inaccuracies can lead to significant financial losses, negatively affecting payments and resulting in financial penalties in RADV and OIG audits. Accurate coding reflects a patients' true health status and ensures providers receive appropriate funding to deliver quality care. With clear visibility into coding practices, MAO’s can assess the quality of vendor work, identify, and rectify coding errors, enhancing overall coding accuracy and minimizing financial and compliance risk.
- Training and education: Investing in vendor training is essential for maintaining coding accuracy. Vendor oversight should include comprehensive onboarding and ongoing education covering the latest coding practices, regulations, and technology. Providing support helps vendors stay competent and confident, leading to improved accuracy and compliant coding.
2. Reduced Data Risk
- Security and privacy: Protecting patient information is more critical than ever with the rise of sharing digital records. Having vendors and MAOs work within the same comprehensive software tool significantly enhances data security and privacy. This unified system ensures all sensitive data is stored, accessed, and managed within a controlled environment, minimizing the risk of data breaches. It allows for the consistent application of security protocols and real-time monitoring of data access and activity. This ensures MAOs stay in compliance with HIPAA and other privacy regulations, providing robust protection of patient confidentiality and maintaining trust in the health care system.
3. Effective and impactful collaboration
- Strengthened vendor relationships: Transparency fosters trust between MAOs and vendors. When MAOs have visibility into coding processes, they can engage in timely collaborative problem-solving, leading to stronger partnerships and improved outcomes for both parties.
- Strategic decision making: Having access to vendor coding data provides MAOs with valuable insights for their own strategic planning. Payors can analyze trends, identify areas for improvement, and make informed decisions about vendor selection, management, and future investments in coding technology.
4. Optimized outcomes
- Improved patient outcomes: Accurate coding leads to appropriate care funding, which can improve patient outcomes. When payors can oversee vendor work, they can ensure that beneficiaries receive necessary treatments, resulting in better health outcomes and overall patient satisfaction.
- Efficiency gains: Centralizing operations by streamlining workflows will reduce administrative burdens and expedite issue resolution. Efficient monitoring and analysis of coding activities will save time and resources. Having a “command center” enhances operational performance through the ability to strategically route charts and create intelligent vendor quality coding projects, all within the same platform.
- Financial performance: Effective vendor oversight directly influences financial performance by optimizing risk adjustment processes. Improved coding accuracy can lead to appropriate reimbursements, minimizing financial penalties in regulatory audits. Additionally, it can enhance the organization’s reputation and potentially attract more patients, further contributing to financial stability.
Conclusion
Effective vendor oversight in risk adjustment programs is indispensable for MAOs aiming to mitigate risks and optimize performance. By bringing vendor coding processes in-house and ensuring both teams operate within a unified system, health plans can achieve greater accuracy, compliance, and data security. Investing in vendor training, fostering transparency, and leveraging strategic insights from coding data strengthens vendor relationships, enhances patient outcomes, and improves financial stability. A robust oversight framework empowers health plans to navigate the complexities of risk adjustment with confidence, ensuring sustainable success in an increasingly regulated and competitive health care landscape.
We would love to connect with you to chat about how you, too, can establish your own risk adjustment “command center.” Feel free to visit our website and reach out to us today to learn about the Health Language Risk Adjustment Suite.
Be sure to mark your calendars for our upcoming RISE activities!
RISE webinar:
Make sure to register for our upcoming RISE webinar on August 22 at 1:30pm EST: “Supercharge Your Risk Adjustment Programs with Clinically Trained AI,” presented by our risk adjustment SMEs, Missy James and Kim Rykaczewski. You don’t want to miss it!
RISE West:
Make sure to visit our risk adjustment team at the upcoming RISE West conference, September 11-13 in Colorado Springs, CO, and join our roundtable presentation on Friday, September 13 at 8:00am MT, where our SMEs Kim and Missy will be speaking about vendor oversight!