Risk adjustment is a complex but vital competency accountable care organizations (ACOs) must develop in order to succeed in CMS’s Medicare Shared Savings Program (MSSP). Without capturing a complete, accurate picture of member risk during the reporting year, ACOs risk jeopardizing their benchmark performance and care management effectiveness. However, many ACOs don’t have the internal expertise to implement a successful risk adjustment program.
Healthcare management services organizations (MSOs), especially those sharing financial risk with their ACO clients, can step in to help their ACOs effectively document, code, and manage population risk for Medicare members. Here are four actionable ways your MSO can support ACO clients with their Medicare risk adjustment program.
1. Develop Annual Wellness Visit (AWV) Chase Lists
While members are being encouraged to defer routine office visits in the near-term due to the COVID-19 pandemic, they’ll still need to be assessed either in person or via telemedicine visits later in the year. MSOs can analyze historical data now to help their ACO partners target the highest-risk patients for outreach in the second half of the year, including those with known chronic conditions, comorbidities, or a history of acute healthcare events that could be tied to undiagnosed diseases that aren’t being appropriately documented.
2. Analyze Retrospective Coding Patterns to Inform Provider Engagement Strategies
Provider organizations are proficient in CPT coding because they’ve spent years in fee-for-service models being reimbursed using these codes. ICD coding accuracy, however, can be hit or miss depending on the staffing resources, experience, and supporting technology of the practice. To help ACOs identify specific areas for condition-specific coding improvement, your MSO can perform a historical analysis of ICD claims codes and compare them to the supporting patient charts to determine where codes may be misaligned or missing altogether from encounter claims.
This type of review will help you identify specific providers who may need additional training to support risk adjustment coding, or commonly-missed HCCs where providers may require additional education on proper coding guidelines.
3. Explore Prospective or Concurrent Risk Capture Solutions
In an ideal world, ACOs would accurately capture every risk-adjusting chronic condition for every member during annual wellness visits (AWVs), and ensure appropriate diagnosis codes appear on the encounter claims submitted to CMS. Prospective risk adjustment programs can help physician practices identify potential diagnosis gaps for their Medicare membership and support gap closures at the point of care, removing the need for extensive retrospective chart reviews.
There are a number of prospective risk adjustment activities that your MCO could explore to help your ACOs improve the accuracy and completeness of their upstream condition capture, including:
- Identifying previously documented member conditions for recapture
- Identifying suspected conditions for assessment & treatment
- Providing workflows to help physician offices groom problem lists in advance of patient visits so providers focus their time on the most important patient issues
- Pushing diagnosis gaps into clinician workflows at the point of care to close during face-to-face encounters
- Providing a technology platform to review patient charts concurrently during the claims coding process to ensure each risk-adjusting diagnosis code is supported by documentation that meets CMS guidelines
4. Perform Supplementary Chart Reviews to Capture Chronic Conditions
ACOs, especially those newer to the CMS HCC risk adjustment model, may not be fully and accurately representing their members’ chronic conditions on Medicare encounter claims. Performing retrospective chart reviews can surface risk-adjusting conditions missing from claims, and identify submitted ICD codes that may be missing appropriate documentation, putting the ACO at potential compliance risk.
Using this information, your MSO can help ACOs identify missing or erroneous diagnosis codes that should be adjusted on claims via clerical error reopenings with their MAC, and uncover likely chronic conditions that may need additional assessment and treatment to meet coding requirements for submission on future claims. If acted on by the ACO, these retrospective chart review findings can help bolster their organization’s benchmark performance and protect them from adverse audit findings.
While the traditional chart review process—which entails manually reviewing every page of a patient chart looking for evidence of risk-adjusting chronic conditions—may not be scalable across ACO clients, AI-powered chart reviews can be performed efficiently and accurately so your MSO can provide a true picture of member risk within each ACO’s Medicare population.
Looking for technology to help support your ACO clients’ success? Apixio can help. Explore our risk adjustment for Medicare ACOs offering, or request a consultation to explore with one of our solutions experts.