By JAY BAKER
Clinical insights and quality/care management opportunities provided by board-certified physicians uncover potential risk-adjusting conditions not identified by routine analytics or coder reviews
To achieve a 5-star rating from CMS, Medicare Advantage (MA) plans must master the ability to integrate with healthcare providers, gain insights from data and demonstrate ongoing improvements. The ranking system is used by Medicare beneficiaries to compare health plans, and by insurers to determine quality bonus payments for plans that earn at least four stars. What began as an alternative to fee-for-service Medicare, MA has gained momentum - with enrollment nearly doubling over the past several years.
In 2017, Florida had five MA plans with 4.5 to 5-star ratings, among the highest in the country, but achieving this requires commitment and consistency.
More than one-third of the Medicare-eligible population is now in an MA plan, and three-quarters of MA-prescription drug program enrollees are in plans that have earned four stars or greater. These ratings are important to consumers and tied to bonuses and benchmark rates for the plans.
Successful MA plans tend to be more integrated with their providers across the board. All of the nurses, doctors, lab techs, pharmacists and others are connected by organizational data, business intelligence and effort. This level of connectivity is the surest way to higher care quality.
For example, a patient arrives for a sick visit and is given a reminder about an overdue blood test, or the provider is alerted that patient has not picked up his or her prescription after three days. It's about finding the care gaps. The number one reason for a patient to be readmitted to the hospital is being confused about medications. At the core of physician integration lies the ability to gain clinical insight into risk-adjusting conditions to enhance traditional analytical platforms.
The Key to Physician Integration
The best approach to optimizing clinical insights is with a Physician Record Review (PRR), a two-stage retrospective chart review process from a 1) certified coder and 2) board-certified physician.
The point of such a thorough review is to give physicians the ability to see progress notes for primary care, specialists' hospital charts, radiology and laboratory results that are not routinely used in standard analytics and gain demonstrable actionable information.
What's more, PRR identifies care opportunities in accordance with evidence-based medicine. The best PRR platforms offer physician staff members who are board-certified in their areas of specialty and have extensive risk-adjustment training to uncover the potential for risk-adjusting conditions left undetected by current programs.
Gaining a Complete Picture
PRRs represent one of the best opportunities to focus on Hierarchical Condition Categories (HCCs). Specifically, the PRR platform employs a team of physician reviewers to identify HCCs within each patient chart, annotate risk adjustable conditions (by page number), and integrate these outputs into a broader array of activities.
CMS uses HCCs to reimburse MA plans based upon the health of their members. It pays for the predicted cost expenditures of patients by adjusting those payments based on demographic information, Medicaid status and the severity of illness or patient health status as recorded in medical record documentation.
The PRR platform should also confirm the previous two years of submitted HCCs for clinical confirmation not currently submitted in the calendar year. The goal is to provide a complete picture for the risk-adjustment factor, increasing the accuracy of the patient's risk score and, ideally, creating clean claims and faster reimbursements.
Snapshot of the value of PRR:
- Reviews currently submitted HCCs
- Confirms previous two years of submitted HCCs for clinical confirmation that have not been submitted in the current calendar year
- Identifies new clinically suspected HCCs based on progress notes from primary care, specialists, hospitals, radiology, pharmacy and laboratory results
- Identifies risk factors for clinical interventions for screening of associated chronic illnesses
Action Plans for the Future
For MA plans to reach the top - and stay there - they must go above and beyond. This means planning for the future and preparing for challenges related to patient engagement and quality measures. For instance, CMS's new rule around access standards for consumers would require organizations to add more physicians. When a narrow network grows larger it becomes more challenging to control, which can undermine quality outcomes. Making PRR part of the action plan will be more critical than ever.
Jay Baker is Senior Vice President for Quality and Risk Adjustment Solutions with Advantmed, LLC. He can be reached at email@example.com