5 Reasons to Apply Clinical EHR Data to Risk Adjustment
Arcadia Healthcare Solutions
07/21/2017
Author: Michael A. Simon, Ph.D., Product Manager and Principal Data Scientist at Arcadia Healthcare Solutions
As health plans and their provider networks seize the opportunity to share in the financial upside (and potential downsides) of shared savings and other value based contracts, accurate and complete identification of patient risk becomes increasingly important to the health of the health care business.
For those looking to improve the process of risk identification, we have found that incorporating clinical data from EHRs into the risk adjustment process has positive effects on efficiency and accuracy. For health plans, EHR data dramatically increase the hit rate of the chart review, improving chase list accuracy and reducing the need for chart pulls. For the provider network, EHR data can be a tool to reduce provider abrasion and engage providers in proactive risk management. For a typical Medicare Advantage program, identifying and closing risk gaps proactively at the point of care can mean a $80-160 PMPM improvement.
To get you started on this path, we briefly describe here five major benefits of using EHR data. If any of these seem right for your risk adjustment strategy, you have the opportunity to download a whitepaper explaining, in greater detail, how EHR data can be used to identify actionable retrospective and proactive opportunities to improve risk adjustment accuracy.
Chart review hit rate improvement: from 15% to 60%
Claims are the backbone of risk adjustment, but claims data have some drawbacks. Designed for billing, they lack rich clinical detail and can lag significantly behind clinical data. Supplementing claims data with EHR data yields a more complete and timely picture. By running a “virtual chart audit” of your entire population in minutes, a health plan can target specific charts for review and validation with far greater veracity and speed than with claims only; health plans with a baseline of 15% accuracy may improve their targeting accuracy to as much as 60%. And for the provider organization, such a scan can immediately generate risk cohorts for effective engagement.
Rapidly identify retroactive reimbursement opportunities that can result in $7-12 PMPM
Claims data require supplementation with patient charts to confirm and validate coding. However, there are many cases where having access to EHR data can eliminate the need for a chart pull. Analytics can be used to rapidly scan a combined claims and EHR data set, exposing specific opportunities for direct, retroactive submission. Depending on the risk mechanism, identification of qualified assessments in EHR data along with appropriate documentation can result in immediate compensation. These retroactive reimbursements, easily facilitated through integrated EHR data, can result in $7-12 PMPM.
In-year opportunities require provider engagement – but provider abrasion can be reduced
Timely risk gap closure in the calendar year is essential, but driving recapture can cause provider abrasion in the absence of more actionable evidence. Sending long chase lists to overburdened care teams is as likely to reduce engagement in the process as increase it. However, by providing analytics based on integrated data sets that include the provider’s own EHR data, health plans and provider groups can offer care teams point-of-care tools that easily incorporate risk gap review into pre-visit planning. With identifiable opportunities typically missed at the point of care estimated at $20-80 PMPM, investing in provider engagement can be very worthwhile.
Proactive risk management can identify opportunities worth $80-160 PMPM
For many health plans, the process of risk adjustment has always been reactive, from chasing down charts to qualify historic events to sending out chase lists to bring in a few more overlooked patients before the end of the year. Integrated EHR data offer a transformative opportunity to create a proactive risk management strategy. When health organizations invest in partnering with their providers on this strategy, and provide tools to deliver actionable risk information at the point of care, the benefits can be significant, whether through improved understanding and confidence in risk adjustment to the value of proactive risk review initiatives, worth an estimated $80-160 PMPM.
Avoiding the financial and legal penalties associated with inadvertent overcoding
For many, the focus of risk adjustment has principally been on the identification of undercoding and missed coding opportunities, but recent enforcement actions have underlined the importance of “looking both ways”, identifying both undercoded and overcoded risk. Identifying poorly substantiated claims can be challenging without an enriched data set, but integrated EHR data make it possible to identify unsubstantiated codes, high-likelihood cases, and frequent one-time coders far more rapidly. In the long run, these efforts are invaluable, reducing health organizations’ exposure to and during audits, and improving overall confidence in the risk adjustment process.