Embracing the New Normal: Prospective Risk Adjustment
The healthcare industry is experiencing a significant transformation, shifting towards value-based care. With the shift to the new risk adjustment V28 model and increased pressure for compliance with the recent RADV ruling, prospective risk adjustment emerges as a pivotal strategy for healthcare providers and payers. This proactive approach offers numerous benefits that align well with the goals of improving patient care across at-risk populations and ensuring financial predictability for healthcare organizations. Let’s explore leveraging prospective risk adjustment strategies in your organization, focusing on three key areas: pre-visit planning, point-of-care, and concurrent review.
Pre-Visit Planning: A Proactive Approach to Patient Care
Pre-visit planning is a crucial component of prospective risk adjustment. The process involves preparing for a patient’s visit in advance to make each appointment as efficient and effective as possible. Pre-visit planning includes reviewing the patient’s medical history, current health status, and any gaps in care or documentation that need attention during the patient visit. This pre-encounter review helps validate any conditions that might not have been previously coded but are clinically relevant. This proactive approach allows healthcare providers to anticipate patient needs, close potential gaps in patient care, and avoid being caught off guard by unexpected patient agenda items.
Pre-visit planning also provides an opportunity to close gaps in a patient’s care. For example, during visit prep, the nurse or medical assistant can determine if a patient is due for immunizations or a colon cancer screening. These gaps can be identified using established protocols before the physician portion of the visit begins.
Advanced technology, such as AI, improves pre-visit prep for healthcare organizations. By employing AI solutions capable of surfacing a comprehensive list of suspected conditions and recaptured opportunities alongside evidence from structured and unstructured data, healthcare organizations are better equipped to spot and address potential gaps in patient diagnoses. This proactive approach ensures more accurate risk adjustment and significantly enhances the quality of patient care.
Point-of-Care: Delivering Trusted and Actionable Insights within the Provider Workflow
Integrating patient condition insights into point-of-care workflows, such as diagnosis gaps, significantly enhances risk adjustment processes. By using real-time data from pre-visit planning, predictive analytics, and other advanced technologies, healthcare providers can make more accurate assessments, improving the quality of care.
Technology is crucial in this process, particularly direct integration into EHR workflows. It allows healthcare professionals to access pertinent patient data and receive immediate alerts about potential diagnosis gaps during patient encounters. This integration streamlines the process, aiding in the quick resolution of diagnosis gaps and enabling providers to make well-informed clinical decisions. As a result, this leads to enhanced patient outcomes and more accurate risk adjustment.
These insights also significantly improve the patient experience. It enables healthcare providers to offer personalized, efficient care, fostering a deeper patient-doctor connection. Patients feel understood and valued, leading to increased satisfaction and engagement, as physicians can concentrate on specific concerns without unnecessary questions.
Furthermore, this approach can alleviate physician burnout. Using technology to present relevant patient information and diagnosis gaps succinctly reduces the need for doctors to comb through extensive health histories, saving time and reducing cognitive load. This shift allows physicians to focus on patient interactions and high-quality care without the stress of administrative tasks, improving their overall well-being and mitigating burnout factors. Therefore, integrating actionable insights into patient care enhances clinical decision-making, patient trust, and healthcare professionals’ job satisfaction.
Concurrent Review: Ensuring Accuracy and Completeness
Concurrent reviews are essential for ensuring complete risk capture and accurate reimbursement by checking encounter coding and documentation for accuracy immediately after patient visits. This process not only guarantees that each encounter reflects the patient’s true health status but also maintains data integrity from a compliance standpoint.
Unlike retrospective reviews, which often identify issues well after the fact, concurrent reviews offer clinicians timely feedback, helping preserve the details of the encounter. This prompt correction of discrepancies before claims submission allows for the application of insights to future encounters, preventing the perpetuation of errors in patient records and maintaining data accuracy.
Unfortunately, the major barrier to embracing concurrent review is due to the laborious manual work required with limited staffing to effectively have a successful program. Each review requires reviewing codes and documentation while coordinating with providers, which is time-consuming without disparate workflows happening. With coding teams stretched, programs may only target a limited set of patients to review.
AI-powered workflows simplify the review process, enabling validation of patient documentation and diagnosis accuracy prior to claim submission. By employing technology that consolidates encounter data for streamlined review and integrates clinical query workflows directly into the EHR, this method drastically improves accurate coding and comprehensive documentation upstream, while fostering operational efficiency.
Prospective Risk Adjustment: Enhancing Patient Care and Financial Stability
The healthcare industry’s shift towards value-based care has made prospective risk adjustment critical for providers and payers. It’s a proactive approach that aligns perfectly with the dual objectives of enhancing patient care and stabilizing financial outcomes for healthcare organizations. This blog has highlighted the essential benefits of prospective risk adjustment and its vital role in the changing healthcare environment.
The impact of prospective risk adjustment is evident by focusing on pre-visit planning, integrating reliable insights into point-of-care workflows, and the benefits of concurrent review. Collectively, these strategies enhance patient care efficiency and accuracy, enabling healthcare organizations to navigate and prosper in the era of value-based care. Consequently, prospective risk adjustment is a fundamental strategy for success in today’s healthcare landscape.
Learn more about Apixio’s Prospective Risk Adjustment Suite and how your organization can make a proactive approach a reality today.