While the risk adjustment (RA) process is slowly catching up to become more efficient, there are several ways that payers can improve their workflows and provider relationships. These improvements not only result in better outcomes for payers, but they help improve patient care.

Medical record retrieval is a necessary evil for most payers and risk-bearing entities. It is governed by archaic processes that have been unchanged for nearly four decades. However, certain watershed events over the past few years have impacted retrievals and may start to improve the front intake of medical records.

While the RA process is slowly catching up to become more efficient, there are a number of ways that payers can improve their workflows and provider relationships. These improvements not only result in better outcomes for payers, but they help improve patient care.

This whitepaper delves into the issues surrounding compliant risk adjustment workflows and ways payers and risk-bearing entities can improve their data retrieval.

Limitations of traditional RA workflows

We have numerous conversations with payers about their risk adjustment workflows. Many feel like medical record retrieval projects are just like throwing everything in the air and hoping things land correctly. They have to sort through ICD-10 codes that are buried, unstructured, and disjointed with incomplete histories. When was the last time you felt confident your chart reviews included records from all out of network claims?

While payers take established approaches and develop programs to capture more accurate codes, many still feel like it is a shotgun response where they must go after everything. Add to that the individual providers that use their specific technologies, and payers are forced to retrieve records from nearly a dozen systems. Plus, they often have to turn to manual practices since providers don't want payers entering into their systems and making any changes. This is due to the fact that payers think of themselves and what they need, while providers need to cover all data documentation/data feeds for auditing purposes.

The three main pain points that payers run into with risk adjustment are inefficient data retrieval, inaccurate coding, and lack of provider participation in providing access to medical documentation (including of all diagnoses assessed during a patients visit), retrieval and follow-up.

Inefficient data retrieval

Data retrieval is a critical tool for retrospective and prospective risk adjustment. Unfortunately, outdated processes bog down most data retrieval processes.

The methods of data retrieval have not changed significantly since the 1980s. Payers are forced to handle various data across the spectrum: structured, unstructured, etc. It can be challenging to gather and organize all the necessary data. Other than specific financial sectors, health care stands alone in its dependence on fax machines to send critical information. 

Providers are becoming more comfortable with data and knowledgeable about how they need to code. However, it’s a practice-by-practice, provider-by-provider initiative with no broad and easy step for increasing education.

When payers request medical records from providers, it takes time and resources to hunt through the limited data that has been retrieved. Because medical record retrieval depends on manual processes, it is also prone to human error that limits the number of charts that can be reviewed. Getting access to data is also challenging. There are plenty of new technologies and multiple data-keeping systems, with everyone rushing in with their unique solution. The sheer number of options is overwhelming for physicians, slowing them down and making it more challenging for payers to get the necessary documentation.

Inaccurate coding

For a long time, coding the diagnosis was not something for which payers paid. It was about the services performed and if it was appropriate for the diagnosis. The shift to risk adjustment has changed that, but providers have struggled to keep up with these changes and inefficient workflows.

Most diagnoses have to be recaptured from claims (looking back a period of standard three  years) and a portion of clinical data from the primary care provider’s (PCP) electronic health record (EHR). Payers sometimes rely on hierarchical condition (or HCC) coding tools, but most only analyze internal data within EHR. This is especially problematic for value-based coders who need clinical understanding beyond fee-for-service.

There have been huge strides, such as submitting claims electronically and standardizing them through portals. However, diagnosis data and charts don’t come through portals.

Many risk adjustment models, such as Medicare Advantage, that come through on the claims are not the same as what is in the chart. For example, the chart may include lab results, vital signs, and pertinent information from the client that the provider may not necessarily put in the claims. This lack of added detail can make getting everyone on the same page challenging to ensure the best possible care for patients.

Lack of provider participation in record retrieval and follow-up

One of the significant issues that payers run into is provider participation in the medical retrieval process. Payers struggle to get the necessary documentation, proper notes, and thorough patient follow-up. Usually, this is because providers are too focused on “acute” patient problems at the time of a visit and not on managing their overall chronic conditions. This results in providers becoming overwhelmed, disorganized, or uneducated about the latest coding changes to be active participants in the risk adjustment process

Since providers want to get paid based on the services provided but documenting accurate diagnoses for the patient demonstrates to Centers for Medicare & Medicaid Services (CMS) the utilization of resources and how sick the population for your plan is. Without documentation, CMS has no way to identify the specific diseases which are contributing to high utilization costs. Now that nearly all funding mechanisms for risk-adjusted government programs have ICD-10 coding, providers must understand the value of the diagnosis to the system.

Payers and providers should collectively go after the goal of making the information about the patient—and their different dimensions—available. If it’s going to be available to providers and payers, it has to be portable. In an ideal world, payers and associated providers would have access to the information that is pertinent to them. However, it can be difficult for everyone to quickly access the data that is most important to them.

Ensuring that the most important information is most readily available is currently a challenge for aligning with physicians. For example, if a patient has stroke and is at the hospital, the documentation is important to understand and document the 'history of' diagnosis for appropriate follow up and care management.

Many physicians struggle with the ability to zoom in and out from a time perspective on the chart. Ultimately, they are not acting on a person but on the immediate issues associated with that person. For example, if a patient with uncontrolled Type 2 diabetes has a sore throat, the PCP will treat it but forget to document that they recommended sugar-free throat lozenges.

Understanding the patient’s history and all relevant diagnosis is critical through standardized documentation that objectively describes the patient.

The ability to find information will only become more complex as electronic medical records (EMR) contain more patient data than ever. Current estimates suggest that just one patient generates as much as 80 megabytes annually in EMR data. It can be challenging for providers to sift through all of this data to find what is essential for the patient at that moment.

Provider participation has only gotten more complicated after the pandemic and the rise in telehealth. Providers and payers have learned new technology rules, sets, and processes that can assist with things like when patients move and don't take their medical records with them, online health assessments require audio and visual in many cases, and everything needs to be documented correctly.

Getting providers aligned with the workflow process entails keeping problems front and center where the provider and payer can act on them. However, the current model can keep vital information buried and make sharing medical data with payers cumbersome. This information disconnect makes it challenging to share with payers and other providers. It not only makes it more difficult for payers and providers, but it also keeps the health care system from being able to provide the most optimal care.

To read the entire white paper, including steps to improve risk adjustment and record retrieval, click here.