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Shahyan Currimbhoy

Posted on October 05, 2022 | 3 min read

Third Pass: Risk Adjustment QA and Compliance


Financial Optimization

Regulatory Compliance

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Risk Adjustment QA and Compliance

Compliance is an integral part of any risk adjustment strategy. The goal of capturing HCC codes is to accurately capture the full health status and disease burden of both individuals (and therefore populations) under value-based care. In this sense, the financial incentive is ultimately another tool CMS uses to motivate participants in risk-sharing arrangements towards that accuracy. That’s why robust quality assurance (QA) workflows are a pivotal element to success in risk capture.

Edifec’s risk adjustment solutions are fundamentally evidence based. That is, they derive their outputs (suspects and suggestions) based on all available clinical documentation. In this regard, all available patient data is mined to portray a more accurate assessment of the patient’s RAF score. The RAF for patients and populations tends to be additive because without technology like ours, manually reviewing all documentation on all care delivered is virtually impossible. Furthermore, clinicians are (rightly) more concerned about patient health above all else, leading to opportunities to improve.

That’s where risk adjustment QA strategies and technology come in, ensuring the highest accuracy. Speaking broadly, a strong QA workflow allows for targeted lists to help organizations prioritize and further improve their own accuracy goals. This can be targeting specific HCCs that would benefit from extra scrutiny prior to submission to be mindful of compliance exposure- in that case, surfacing all members with those relevant codes for review. It can also mean targeted lists for sites, individual providers, even coders that could benefit from educational opportunities that QA would offer. The benefits are not limited to redaction, either. Downside exposure from upcoding is a high priority of any QA process, but there are additional applications. For example, double checking the complete HCC capture of conditions providers or coders may not be as familiar with, i.e., those that are emerging in a population or are newly added to a relevant risk-model, becomes much more achievable. This is especially true for transitional expertise: as ACA and Medicaid risk adjustment climb the priority ladder, the coding idiosyncrasies of each will need some time to be internalized by all parties. Finally, even prior instances of code removal are available for QA, e.g., the redactions can be restored if clinical evidence is deemed sufficient downstream.

Still, those benefits to risk adjustment QA are meaningless if user-level efficiency is lacking. The volume of data and submissions needs to be accounted for to allow for success. As is the case with the mainline workflow of our solutions, if a member is identified in a targeted list for any reason, and they have ten applicable documents that could potentially be reviewed to resolve the findings, but only two pages have relevant information, only those two pages will be surfaced to users. Similarly, as is the case with our Retro Review’s primary workflows, work queues are split among teams to allow for simultaneous, non-conflicting reviews, each customizable by managers. Finally, there are manager-specific queues that can be used to double check other reviewers as an additional layer. This all allows for a sophisticated, multi-layered approach to QA (and therefore risk capture as a whole), with different users focusing on different elements of a more complex need.

Edifec’s solutions are powered by incredibly sophisticated and highly accurate artificial intelligence. However, the goal of our solutions is to empower human expertise to perform better with greater efficiency. By adding additional layers of expertise through customizable QA workflows on top of prior coder interactions, the dream of complete, accurate, compliant risk capture has never been closer to a reality.

If you’d like to ensure your organization’s risk adjustment technology is helping you achieve at the highest level, reach out to us today.

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