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Risk Adjustment Never Sleeps

A Four-Part Series by Will Stabler

Click here for a PDF of the entire series

About This Series

I wrote this article series in four parts over two months during the height of the coronavirus  pandemic to examine how the pandemic and its lockdowns affected those in the business of risk adjustment, and what happens with the industry as the world returns to “normalcy.”

Articles in This Series

1. New Risk Adjustment Realities Amid the Coronavirus Pandemic
Introduces the series and addresses short-term adaptations in the industry, enhanced support for telehealth services, and reiteration of the need for EHR connectivity and interoperability.
 
Examines some of the options for reopening, making the best use of time in the transition, and taking advantage of new opportunities in provider/health plan partnerships. 
 
Explores some the gradual reopening of the healthcare industry, including patient outreach and the point of care, how Medicare Advantage and other plans can help support member health needs, and the effects the pandemic has had on the IT interoperability issues in health care.
 
Addresses what the priorities should be in RA in the end of 2020 and beyond, how best to use time and resources in the new environment, and looks on the positive side of what the industry has gained from the COVID experience.
 
 
 
 

New Risk Adjustment Realities Amid the COVID-19 Pandemic

By Will Stabler

First published on May 3, 2020

The COVID-19 pandemic has sent a tsunami through every industry on the planet, and those of us who work in the business of risk adjustment (RA) are not immune from its effects. Surviving this pandemic means toughing it out, but truly thriving through it is all about finding opportunities and re-imagining how we operate while we are living in a bleak new environment for doing so.

In this series I will look—primarily through a Medicare Advantage lens—at the COVID-19 pandemic from the standpoint of its near-, medium- and long-term effects on the business of risk adjustment and the professionals working in this novel RA landscape. I will also consider changes that are already happening in the broader risk adjustment world in both the government and business sectors because of the pandemic, highlighting opportunities in where things seem to be heading.

As the end of 2020 rapidly nears, it is time for thinking forward toward your goals for the new year, whether you want to call them resolutions or not. For many reasons that I won’t go into detail here, 2021 promises to present less of those situations that take the control of our destiny out of your hands. In this article I want to show you how to put control over your goals into your hands and provide you with tools to help you reach them. Let’s start with your motivation for setting them.

Where are we going in this series?

Among the places we will venture in this series are:

  1. What do we do now? This first part of the series will look at what challenges and potential opportunities COVID-19 is already bringing to the RA business. How do we keep our people and organizations healthy and safe, while complying with all state and local guidelines for continuing to operate? I will explore the role of telehealth and look into opportunities of operational efficiencies, education and critical activities in pursuing maximum return, to include building more electronic retrieval capacity and EMR integration.
  2. How do we navigate “pseudo normalcy” and what does that look like in risk adjustment? Eventually, pressure will ease on healthcare systems, and member outreach and support will need to begin to ramp up. This part of the series will address how to facilitate this contact with enhanced telehealth and online options. More information will need to be integrated into provider EMRs to facilitate these relationships. Also, the pandemic has the potential to greatly worsen the impact of social determinants of health (SDoH) as more and more people experience social isolation/loneliness, food insecurity and housing instability. SDoH may need to be considered more broadly in medical management.
  3. What happens when the team is back to work? The lockdown will eventually end and all the pieces of the healthcare system will fall back into place, but likely not into the same space as they were before. Both MA and provider organizations will need to plan for this well in advance so they are prepared to launch with all elements of people, process, and technology ready to go. People with chronic disease will likely be much sicker after months of being told they can’t see their caregiver and not being properly monitored for their conditions. Care gaps that had been previously identified will remain unaddressed, so EMRs will need to be enhanced to facilitate better tracking. In this part of the series we will address the elements of ramping up, including retrieving as many records as possible that might require in-person scanning in case “ramping down” again becomes necessary.
  4. How do we make sure we are ready for 2020 year-end? From what we have seen so far, the only thing certain about COVID-19 is uncertainty. MA organizations and providers alike need to plan for today’s reality to be the new normal, so we need to adjust our mix of tactics. Procrastination on reporting is no longer an option. Health plan/provider partnerships will be more important than ever in easing the burden of regulatory reporting requirements, improving care quality, and reducing costs, and this will be the opportunity to strengthen them. This will also be the time to advocate with CMS to not only ensure that greater acceptance of telehealth becomes permanent, but also to encourage other approaches and models, including automatic revalidation of long-term conditions that do not go away.  

Adapting in the Near-Term

By now most organizations working in RA have adjusted to the physical aspects of working in the new “stay at home” reality. We have our offices set up at home and we have worked the kinks out in Zoom or Skype or whatever modality we are using to communicate with our staff and providers.

So now we are much more technologically adept (right?), collaborating and sharing information almost exclusively by electronic means. Unfortunately, if you are like most people in this business, generally speaking, that was not what you were doing before the restrictions of the pandemic forced this on you. Back then (seems like such a long time ago) most of the information you had collected for retrospective review once you were locked down was on paper. And if you were behind in that process at the time, you now are facing more challenges than those who were more reasonably ahead of the game.

Many in RA have been harping on the need for electronic medical record connectivity and interoperability for years, and I consider myself to be one of the loudest in the choir. I just thought that one or several among us would be the champions driving the process—not some evil, mutating, microscopic monster.

As it has always been in nature, those who adapt tend to survive and thrive, so continue with your retro record collection and review process with the limitations that have been placed on you by not being able to meet with your contacts on site. But also focus on developing greater capacity in electronic retrieval methods with vendors or establishing EMR connectivity where you can. 

One improvement goal to consider during this period is developing incremental incentives for establishing electronic connectivity. It will help future-proof operations if a potential second wave of coronavirus hits later this year or continues to persist into the future. Any planning you do at this point must take into account that we could soon be back in lockdown once things start opening up again. Connectivity is just one opportunity that has been created/accelerated in this new environment. Telehealth is another, and its time may be finally here.

Telehealth Gets a Shot in the Arm

On April 10, the Centers for Medicaid and Medicare Services (CMS) sent a letter to all “Medicare Advantage, Cost, PACE and Demonstration Organizations” that has been a long time in coming titled, “Applicability of diagnoses from telehealth services for risk adjustment.” The letter starts: “The 2019 Coronavirus Disease (COVID-19) pandemic has resulted in an urgency to expand the use of virtual care to reduce the risk of spreading the virus; CMS is stating that Medicare Advantage (MA) organizations and other organizations that submit diagnoses for risk adjusted payment are able to submit diagnoses for risk adjustment that are from telehealth visits when those visits meet all criteria for risk adjustment eligibility, which include being from an allowable inpatient, outpatient or professional service, and from a face-to-face encounter.”

The letter provides these details: “In order to report services to the EDS that have been provided through telehealth, use place of service code ‘02’ for telehealth or use the CPT telehealth modifier ‘95’ with any place of service.”

Based on this guidance for use in risk adjustment, we need to keep up vigorous support and advocacy for the use of telehealth through IHAs or provider office leads. Urge provider offices that might not have previously established a capability to consider identifying a telehealth capability vendor that can be made available for their offices. Develop provider education on telehealth coding and documentation requirements. Consider modifying provider incentives to encourage the use of this modality in assessing and managing patients. 

Other ways to support provider networks in using telehealth include:

  • Providing education about requirements of telehealth visits
  • Providing sourcing options for those providers, typically smaller, that do not have telehealth capability
  • Introducing temporary incentives to encourage telehealth visits, particularly in conjunction with Annual Wellness Visits (AWVs). This is a great modality for focused conversation about annual health and wellness planning and confirmation of long-term conditions. 
  • Identifying members and patients requiring support via telehealth for outreach
  • Supporting provider outreach through tools, scripting, and best practices. Layer in scheduling support for those providers that cannot address that on their own. 
  • Conducting outreach to members about telehealth options to ensure they are primed when providers conduct outreach. 

 

This lockdown period is the prime time to take advantage of new telehealth opportunities that have been created by the pandemic in closing emerging care gaps that are likely being created by the crisis and resultant restrictions on access to care.

Where provider networks are not able to use telehealth, layer in telehealth in-home assessments for members. There can and should also be linkages with care management support as well as battery of assessments related to SDoH that provide referral points. 

Remember, there will be an eventual transition to opening back up. And there will also be the possibility that we will be forced to go back into severe social-distancing again.

What to do during that transition will be the focus of the next article in this series.