How can we integrate the value of risk adjustment into QI models?

In response to the pandemic, the Department of Health and Human Services designated new e-visit codes for the 2020 calendar year. Shifting our perception of health assessments and taking advantage of virtual care technology will improve Hierarchical Condition Category (HCC) performance and quality of care. Integrating workflows and data models into the risk adjustment process can help providers address HCC diagnoses and quality measures during the patient visit, minimizing the risk of inaccurate and reduced CMS payment.  

In these uncertain times, it’s a good idea to be flexible. Let’s explore strategies where providers and health plans can address patient needs and maintain accurate HCC documentation and quality performance in the face of COVID-19. 

Prioritize preventive care 

The majority of patients who didn’t have an AWV by June probably won’t have one by the end of the year unless they are contacted by their provider. We’re approaching the last quarter of the year, so now’s the time to identify patients who haven’t had their Medicare Annual Wellness Visit (AWV)—to address gaps in care, perform recommended screenings and mitigate the impact on utilization resulting from postponed/avoided care.  

Prioritizing analytics and data to help close gaps  

CMS will be adding an additional reconciliation run for risk adjustment data submission for PY2020 with an interim reconciliation on 02/02/2020, followed by a final run 08/02/2021. Providers will have additional time to work with their care teams to correct claims, perform chart reviews and submit supplemental data in 2020.  

Consider evaluating your organization’s analytics platform or partnership with a risk adjustment analytics platform to identify missing codes, close gaps and better manage patient care—both retrospectively and prospectively. 

ACOs and extended risk timelines 

Changes in CMS guidelines note that accountable care organizations may maintain their current risk level through 2021 instead of automatically advancing to the next risk level, enabling them to plan for a model that will result in a more accurate reflection of risk. 

Incorporating risk adjustment in your telehealth approach 

Waivers have been passed and reassessed as a response to COVID-19, to facilitate flexibility and expand coverage. Added HCCs that can be captured
include: 

· HCC1: HIV/AIDS 

· HCC19: Diabetes without Complication 

· HCC27: End-Stage Liver Disease 

· HCC56: Substance Use Disorder, Mild, Except Alcohol and Cannabis 

· HCC70: Quadriplegia 

What does a prospective use case look like when it is integrated with provider engagement, data and telehealth models looking to impact Star Ratings? Here’s an example: 

A patient with uncomplicated type II diabetes is scheduled to see the PCP for an annual wellness visit via telehealth videoconference. Before the visit, the PCP receives an EHR alert to check the patient’s urine protein
level. The alert also indicates that the patient’s previous urine microalbumin/creatinine ratio was elevated and that the patient might meet clinical criteria for Diabetic Nephropathy (E11.21). The provider orders a microalbumin/creatinine ratio test and documents a diagnosis of diabetic nephropathy. 

Integrating existing patient engagement initiatives while leveraging technology and prioritizing preventive care and clinical outcomes can streamline the risk adjustment and data capture process, especially as organizations build a model to support ACO functions in the future.  

What are your thoughts? Share in the community forum.  

1. What strategies has your organization implemented to help providers with coding and documentation? 

2. What challenges has your organization encountered to engaging patients to capture a diagnosis during telehealth visits? 

3. What strategies does your organization use to monitor benchmarks, to assess investing in risk adjustment at an appropriate level?