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6 Physician Benefits of Prospective Risk Adjustment

Under pressure from CMS to move away from retrospective risk adjustment and capture patient risk more accurately on encounter claims, many physicians are being provided with tools and incentives to participate in prospective risk programs—that is, programs that provide physicians a list of patients with suspected risk-adjusting conditions to improve coding and documentation at the point of care.

On the surface, these programs may seem purely financial in nature. After all, the primary goal of moving risk capture upstream is to improve ICD coding accuracy so plans and providers can receive risk-related payments sooner and reduce the need for costly retrospective chart reviews. However, both parties can reap benefits from prospective activities beyond reimbursement. On the provider side specifically, reliable condition suspect data can help physician offices improve patient outreach, care management, and operational efficiency.

Let’s explore 6 potential benefits of prospective risk adjustment programs for physician practices and groups.

Benefit 1: More Targeted Annual Wellness Visit (AWV) Chase Lists

Equipped with timely and actionable information on suspected conditions for the patient, physician staff can identify higher-risk patients and conditions to target for annual wellness visit (AWV) outreach campaigns. By proactively nudging patients to come in for an appointment early in the year, physicians can perform necessary health assessments, proactively treat the patient’s conditions and close any care gaps.

Benefit 2: Better Problem List Prioritization

Patients with multiple comorbidities or complex health histories can have long Problem Lists in an EHR. Using prospective risk data, physician staff can flag high-priority conditions ahead of an in-person encounter, helping the provider focus their attention on the most impactful health issues requiring proactive care management during the patient’s visit.

Benefit 3: Pre-Encounter Condition Suspecting

An individual practice often has gaps in information for newer patients or patients who receive care from specialists at outside medical groups. With condition suspect information based on a broad set of clinical and claims data, clinical staff can gain insight into conditions a patient may have and identify the highest priority items for the physician to assess, treat, and document at the point of care.

Benefit 4: Improved Preventive Screening Compliance

With condition suspect information integrated at the point of care, physicians can more effectively recommend preventive screenings and other diagnostics. This will not only provide more targeted preventive care services and help catch potential health issues upstream, but it will also have a positive impact on quality measure compliance for HEDIS, Stars, and other programs that focus on preventive screenings.

Benefit 5: Smarter Care Routing and Referrals

Prospective risk data can help physicians develop a more complete, longitudinal record of a given patient’s health. After performing the necessary assessments, a physician can make more informed decisions about what type of care a patient should receive, whether that’s a specialist referral, case manager assignment, enrollment in an educational course, or additional support from a SDoH program.

Benefit 6: Reduced Operational Overhead

While prospective risk adjustment adds a few additional steps before, during, and after a patient visits, this upstream work will ultimately reduce operational overhead for physician offices. If accurate condition suspect information is presented within the physician’s workflow and appropriately acted on at the point of care, there should be fewer after-the-fact documentation gaps to close, patient charts to chase for retrospective risk programs, and follow-up appointments to schedule, reducing abrasion, time, and cost of these administrative activities.

In Summary

Prospective risk adjustment can have a much bigger impact on physicians than simply helping them improve ICD coding on claims. These programs, if implemented successfully, have the potential to streamline practice operations, help caregivers focus on the most important issues during patient encounters, and improve care recommendations and outcomes with a more complete picture of patient health.

Looking to move to prospective risk adjustment? Explore Prospective Insights, Apixio’s AI-powered condition suspecting solution.

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