As providers continue to expand their value-based contracts with payers, the administrative burden on clinical teams can be daunting, especially around documentation and coding. In order to best meet value-based care initiatives and avoid clinical burnout, healthcare teams would do themselves, and their patients, a service by participating in a prospective risk adjustment program —that is, a program that provides clinical teams a list of patients with suspected risk-adjusting conditions to improve coding and documentation at the point-of-care.
On the surface, these programs 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 payers and providers are reaping benefits from prospective activities beyond reimbursement. On the provider side, reliable condition suspect data can help clinical teams improve risk capture, care management, and operational efficiency.
Let’s explore 6 potential benefits of prospective risk adjustment programs for providers and their clinical teams.
Benefit 1: Proactively Close Care Gaps
Equipped with timely and actionable information on suspected and recaptured conditions for the patient, clinical staff can identify for the provider the higher-risk patients and conditions to target during point-of-care. In doing so, providers are empowered with actionable patient insights to proactively evaluate and manage the patient’s conditions and close any care gaps.
Benefit 2: Pre-Encounter Condition Suspecting
An individual practice often has gaps in information for newer patients or patients who receive care from 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 provider to assess, treat, and document at the point-of-care.
Benefit 3: Improved Preventive Screening Compliance
With condition suspect information integrated at the point-of-care, providers can more effectively recommend preventive screenings and other diagnostics. This process will provide targeted preventive care services and help catch potential health issues upstream. It will also positively impact quality measure compliance for HEDIS®, Stars, and drive value-based care initiatives.
Benefit 4: Smarter Care Management
Prospective risk data can help clinical teams develop a more complete, longitudinal medical record. After performing the necessary assessments, a provider can make evidence-based 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 an SDoH program.
Benefit 5: Increased Alignment With Utilization Management
With the ability to better capture suspected conditions, clinical teams are able to develop a more accurate and complete patient phenotype. Using this phenotype as the source of truth, utilization management teams can make better-informed determinations of medical necessity, which has the downstream effect of improving prior authorization request responses – one of the highest impacts on provider abrasion.
Benefit 6: Reduced Operational Overhead
While prospective risk adjustment adds a few additional steps before, during, and after a patient visit, this upstream work will ultimately reduce operational overhead for clinical teams. By presenting accurate condition suspect information within the provider’s workflow – that can be 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, if implemented successfully, can:
- Streamline practice operations
- Help caregivers focus on the most important issues during patient encounters
- Improve care recommendations and outcomes with a complete picture of patient health
- Support value-based care program success
Looking to move to prospective risk adjustment?
Explore Apixio’s AI-powered Clinical Guidance solutions.