While risk adjustment programs have faced growing challenges with accuracy, scale, and ROI over the past few years, COVID-19 has exacerbated these challenges overnight.

We’re currently in a season of upheaval—for our world, our nation, and our industry. If there’s one positive we can take away from the pandemic, it’s that drastic and sudden change can provide a healthy impetus to rethink the status quo. This principle has already played out in many aspects of health care—infectious disease protocols, telehealth adoption, PPE manufacturing, drug trials, and vaccine development, to name a few. But it also applies to administrative aspects of health care, foremost among them being risk adjustment.

Many risk adjustment programs have followed the same playbook for years, relying on costly onsite chart retrieval programs, inefficient manual chart reviews, and onerous internal audits to capture chronic conditions and ensure program compliance. Today, there’s an opportunity for risk adjustment teams to invest in new technologies, tools, and processes to protect their performance in the short term and build a stronger foundation of success for years to come.

Risk adjustment program challenges in the time of COVID-19

While risk adjustment programs have faced growing challenges with accuracy, scale, and ROI over the past few years, COVID-19 has exacerbated these challenges overnight. A few of the emerging issues we’re seeing in the market include:

  • Chart retrieval delays. Hospitals are underwater trying to keep up with COVID-related patient care, and many other provider groups have shut their doors or significantly downsized during the pandemic. As a result, payers are currently unable to retrieve charts onsite, and may not be able to do so for the foreseeable future.
  • Compressed coding and audit timelines. If chart retrieval activities can’t happen until later in the year, coding and auditing projects won’t be able to start until much later than usual, adding strain to already compressed submission timelines.
  • Reduced coding vendor capacity and productivity. Many coding vendors, particularly overseas vendors in quarantined areas, may not be operating at 100 percent capacity until shelter-in-place restrictions are lifted due to internet connectivity issues or security concerns. Additionally, coders working from home for the first time may see some lag in productivity while they get used to a new environment or juggle professional and personal obligations.
  • Increased compliance risk. Chart reviews rely on human decision-making, and during times of high stress, people tend to make more mistakes than usual. COVID-19 has caused additional stress for everyone, which could put risk adjustment programs at greater compliance risk during future RADVs, IVAs, and other regulatory audits.

Why now is the time to invest in risk adjustment technology

Technology can’t solve every problem, but it can help teams address all the issues highlighted above. With a coding platform that incorporates artificial intelligence (AI) techniques like natural language process, machine learning, and deep learning, your organization can improve coding accuracy, efficiency, and defensibility, even with tight turnarounds. AI-generated HCC predictions can help reviewers focus their attention on high-value charts where risk-adjusting chronic conditions are most likely to be found. Other AI models can compare known codes to supporting documentation in patient charts and flag potentially unsupported HCCs that need remediation. Lastly, a cloud-based coding platform can help streamline project management tasks for remote coding teams by automating review & audit assignments, tracking coder performance metrics, and showing real-time progress toward project completion goals.

What to look for in a risk adjustment technology partner

Not all risk adjustment technology offerings are created equal. When bringing on a new vendor, you want to make sure you’re choosing a partner who can support your program’s needs both now and in the future. A few of the things to look for in a technology vendor include:

  • Scale. Can the vendor’s system handle high volumes of data processing and concurrent users? The last thing you want is for your coding platform to suffer from performance issues during peak busy season.
  • Client roster. Does the vendor work with reputable plans and providers? What does the vendor’s client retention rate look like? Does the vendor have references you can contact?
  • Project results. What value have the vendor’s clients seen during coding and auditing projects? While ROI is important, it’s not the only metric to consider. Coding speed, reviewer productivity and accuracy, transparent performance tracking, and stats around provider coding and documentation trends are all important results to explore through case studies, sales conversations, and reference calls.
  • Technology approach. How does the vendor employ artificial intelligence (AI) in its solutions? Some vendors use simple rules-based algorithms to locate potential HCCs in charts, surfacing lots of results without a lot of precision. Others employ more sophisticated machine learning techniques that accurately predict supported or unsupported HCCs, supporting greater productivity and a better user experience for coders.
  • Data accuracy. What does the vendor’s data onboarding process look like, and how rigorous is its internal QA program? If your project isn’t set up with the right member crosswalk, subtraction data, or claims files to pair with patient charts, you may run into serious issues later during your coding or audit projects. The vendor should share responsibility for ensuring project data is accurate and complete.
  • Implementation requirements. How much does implementation cost, and how long will it take to get your first project up and running? Some vendors charge hefty setup fees or take months to onboard a new client, which may not align with your program goals and timelines.

In summary

If your risk adjustment program has put off adopting technology in the past, now is the time  to try something new. Given the added pressures on the chart review and audit process this year, investing in a proven technology solution can give your team the boost in accuracy and productivity it needs to stay on track with CMS and HHS coding submissions.

Looking for a retrospective coding, prospective risk capture, or compliance technology partner to support your risk adjustment program? Apixio can help.