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Shahyan Currimbhoy

Posted on November 02, 2022 | 3 min read

Risk Adjustment and Revenue Cycle: Benefits and Steps to Success


Financial Optimization

Value Based Care

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Risk adjustment and revenue cycle are becoming increasingly intertwined as more providers take on larger risk contracts under value-based care, shifting the mix away from traditional fee-for-service. Historically, risk adjustment has been dominated by retrospective reviews for the purposes of supplemental submissions. However, the same cashflow pressures that drive focus on revenue cycle performance are spurring provider organizations to find a timely alternative to multi-year reconciliations for complete and accurate risk capture. As a result, there’s an internal incentive to move HCC coding from a retrospective workflow into daily revenue cycle operations.

This is one of the primary principles that led to the development of Edifecs Post Visit Review. How can the completeness and accuracy of this solution integrate risk adjustment and revenue cycle for provider organizations? More than that though, what other unique challenges could be addressed by this “upstream” approach to HCC coding?

  1. More rapid care funding. The traditional financial benefit of risk adjustment is achieved faster, diminishing the reliance on retrospective payments for provider organizations.
  2. Compliance is supported. Like Edifecs Retro Review, Edifecs Post Visit Review offers two-way coding review, meaning billed codes that lack sufficient clinical support are suggested to coders for removal. This means inaccurate claims don’t make it out the door in the first place.
  3. Improved quality of care. Patient records, and therefore health profiles, are gathered thoroughly, completely, and more rapidly, enabling more holistic care plans going forward.
  4. Real-time, actionable data for clinical documentation integrity (CDI) initiatives. The near real-time data feedback on encounters that need to be altered to accurately reflect a patient’s health, either through code addition or removal, creates better “of the moment” opportunities to guide providers and coders alike as they transition to value-based care and away from traditional fee-for-service mindsets.

Benefits aside, change can be its own challenge. And to truly understand the inflection of risk adjustment and revenue cycle means also understanding the immediate and long term concerns of revenue cycle managers. For example, adding additional risk-focused coder review can feel like an additional upfront expense and impact to front-end performance metrics. However, using a pre-submission workflow for risk adjustment radically accelerates payments, avoiding a “charge lag on steroids” phenomenon. Still, there are steps that can be taken to support risk adjustment and revenue cycle goals concurrently. For example:

  1. Integrate HCC operations with the broader revenue cycle strategy. There are a number of factors revenue cycle leadership need to consider when incorporating a risk-focused workflow into their operation. The most important impact for them will likely be where the risk-focused, pre-claim coder review will situate in the larger cycle. Whether before or after AR (accounts receivable) creation, it’s important to understand the broader impact on the extant revenue cycle metrics for that lifecycle segment. Even though it’s a large net-gain for an organization, it can be difficult to remember that as metrics adjust. Expectations will need to be adjusted accordingly. In assessing the introduction of risk coding’s impact on the revenue Cycle and weighing it against the benefits of the risk-adjusted payments (and other benefits), organizations can align themselves to a comprehensive strategy that optimizes performance for each of the vital revenue streams.
  2. Understand your contracts. This is more than just population mix. Understand the amount of risk shared with payer partners. It can also change depending on the contract year, as is the case with MSSPs, ACOs, and direct contracting entities. The risk share should impact revenue expectations, and in turn help calibrate the size and scope of an HCC coding operation. As organizations move from early, partial-risk contracts to full risk and full capitation arrangements, the impact to traditional FFS revenue is reduced, and the importance of comprehensive risk coding increases.
  3. Know your mix of specialties and their likelihood of high performance with risk capture. It’s widely understood that primary care providers provide the bulk of clinical condition documentation, but there are a number of specialties that can impact risk adjustment, generally those who address chronic conditions or otherwise take on a roll of managing care: endocrinologists, rheumatologists, OBGYN, cardiologists, etc. Them having an internal understanding of the prevalence and mix of HCC-eligible documentation within a practice or specialty will drive sound decision making when determining how to route patient encounters through coder reviews.
  4. Optimize your EHR for targeted review. Edifecs Post Visit Review can automatically process and filter encounters to find eligibility and opportunity for improved risk capture accuracy. However, the process can be further refined inside the EHR itself to avoid non-eligible visits from entering a bill hold in the first place. This will only further accelerate the revenue cycle operations.

Risk adjustment and revenue cycle can, and should, operate hand in glove. As value-based care continues to grow, these transitions will become more common and more well understood. In the meantime, we’re here to help. If you have any questions, contact us today.

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