The pandemic-era risk-adjustment challenges facing healthcare payers and risk-bearing providers are numerous, and they are not limited to the persisting economic impacts of COVID-19. Technology is vital to overcoming current barriers and clearing those on the horizon.
Many providers are struggling with financial woes and staffing shortages, and providers and payers alike are scrambling to adapt to evolving government policies and care standards. Meanwhile, a growing number of patients using telehealth means more patient assessments are also completed via telehealth, rendering them ineligible for risk-adjustment determination. And even before the pandemic and healthcare labor crisis, payers were devoting an inordinate amount of time and effort toward risk-adjustment modeling based on hierarchical condition categories (HCC).
The technology utilized by a comprehensive, risk-adjustment platform can help providers cope with staffing shortages, workflow delays and revenue disruptions. It can speed the shift to meet new healthcare initiatives and regulatory criteria, such as those associated with interoperability and electronic medical records (EMRs). It offers a wealth of data that can help payers and risk-bearing providers make confident, informed decisions to improve workflow, elevate quality, maintain compliance and develop value-based strategies.
An advanced, single-source, risk-adjustment system like iCode Risk Adjustment (iCRA) is a powerful, self-service tool that offers real-time reporting and actionable risk-adjustment data. Following is a closer look at the benefits of iCRA technology and how payers and risk-bearing providers can utilize this technology to enhance their risk-adjustment initiatives.
One key benefit of a single-source, risk-adjustment service is potential cost savings compared with purchasing, maintaining and updating internal technology, which requires hardware, software and staff. GeBBS Healthcare Solutions found that its partners realized an approximately 50-percent reduction in house technology costs via implementing iCRA.
And consider that the data processed by state-of-the-art risk-adjustment platforms offer additional opportunities to identify savings and improve service quality. A study published in The Journal for Electronic Health Data and Methods indicated that algorithm-based, risk-adjustment modeling could help reduce overall care costs by predicting patients’ future cost status and determining eligibility for care management.
Likewise, a recent Health Payer Intelligence article detailed how the patient-access application programming interfaces (APIs) related to risk-adjustment technologies and other interfacing software could be leveraged to optimize risk-adjustment efforts. Modern risk-adjustment platforms are built to meet interoperability guidelines and enable data sharing between payers and providers, supporting improved risk management and leading to more timely payments and more informed care management.
A major pain point in the move to meet interoperability requirements established by the Centers for Medicare & Medicaid Services (CMS) — and an obstacle made more glaring by the ongoing labor shortage — is medical records retrieval. Even in late 2020, just months before the pandemic rocked global healthcare and economies, a Healthcare Finance News article reported that many payers were floundering to meet CMS interoperability standards, particularly those related to chart retrieval.
iCRA chart acquisition technology makes compliance straightforward and secure. Its user portals align with Health Insurance Portability and Accountability Act (HIPAA) standards, and it features EMR integration and EMR-continuity of care (CCD) data exchange while accommodating fax, mail and onsite retrieval.
The iCRA platform improves overall data capture and provides real-time tracking of parameters, including chart acquisition status and exception distribution. It can also contribute to reduced chart retrieval costs.
The iCRA solution features a real-time, risk-adjustment detail dashboard that breaks down risk adjustment factor (RAF) score reporting by plan, group or individual members. The artificial intelligence (AI)-enabled platform also employs natural language processing (NLP) to improve RAF reporting.
In a 2021 article for the Resource Initiative & Society for Education (RISE), GeBBS Healthcare Solutions discussed how AI and NLP technologies can automate risk-adjustment processes and the value of automation. Payers can further exploit this technology to help ensure its risk burden is accurately reflected, promptly identify and address errors, strengthen connections with providers, and position themselves at the forefront of the healthcare landscape.
The iCRA system is designed to improve code capture for RAF reporting accuracy, which can lead to better RAF scores and boost return on investment. The dashboard further provides dynamic insights to inform sound decision-making, such as how certain diagnoses would affect the RAF score.
A recent Health Affairs article about risk scores relative to Medicare Advantage noted the importance of RAF scores in cost reduction, performance improvement and profitability. GeBBBS’ internal case studies show that iCRA partners achieved an average 0.75-plus increase in RAF scores and experienced a median 20-percent increase in reimbursements based on RAF calculations.
Adherence to the Healthcare Effectiveness Data and Information Set (HEDIS) is more crucial than ever since its development decades ago by the National Committee for Quality Assurance. According to the latest data from the U.S. Department of Health and Human Services, more than 90 percent of U.S. health plans use HEDIS to gauge care and service performance, and nearly 200 million people are enrolled in health plans that report quality results based on HEDIS benchmarks.
Likewise, Medicare’s Star Rating system has resonated with Medicare Advantage and Part D members, as well as payers. According to the newest CMS Star Ratings, approximately 68 percent of Medicare Advantage plans with prescription drug coverage will rate 4 or 5 stars out of 5 stars in 2022, a jump of nearly 50 percent from 2021.
The iCRA solution incorporates HEDIS abstractions with real-time and retrospective data that help payers identify gaps and improve quality. The iCRA analytics platform also captures more than 60 quality metrics used to calculate CMS Star Ratings.
The iCRA technology allows payers to recognize individual quality gaps and address those gaps directly through a searchable chart repository. The platform’s integrated workflow also offers the ability for external overreads and medical record review validation (MRRV). GeBBS’ partner case studies have demonstrated a 95-plus percent increase in medical record abstraction and approximately 98 percent abstraction quality.
The multifaceted capabilities of AI and NLP extend to risk-adjustment analytics and reporting. These technologies drive accurate and efficient coding and data validation and empower rigorous quality assurance (QA) initiatives.
The iCRA dashboard is customizable and provides secure, transparent access to all data so clients can tailor the depth of their analytics and reporting. It can process targeted diagnoses in real-time, and it offers the ability for second- and third-level coding reviews while reducing the need for multi-level reviews.
Capturing more data more accurately on a first pass contributes to cost savings and workflow improvement. It also yields an immediate abundance of contextual data that can help guide risk-score improvements, strengthen payer-provider interface, inform revenue strategies and advance patient care.
Technology must also be user-friendly for those who interface with it to be effective. The iCRA platform is simple to implement and easy to personalize to a payer’s or risk-bearing provider’s unique needs. It equips risk-adjustment leaders with the ability to manage internal teams, processes and vendors from a single, robust resource.
GeBBS Healthcare Solutions is an acclaimed leader in healthcare risk-adjustment technology and services for payers and risk-bearing providers.
GeBBS is dedicated to our partners’ success, and we support our clients with an experienced team of skilled coders, auditing experts, EMR specialists and IT professionals. GeBBS is recognized as one of Modern Healthcare’s Top 10 Largest Revenue Cycle Management Firms, Black Book Market Research’s Top 20 RCM Outstanding Services and Inc. 5000’s Fastest-Growing Private Companies in the United States.
Contact GeBBS at gebbs.com to schedule a consultation and demonstration, and see for yourself how we can help you optimize your risk-management strategies to meet today’s challenges and prepare for those ahead.