The introduction of the Affordable Care Act in 2010 also brought forth a section that shared a permanent risk adjustment program. Its goal was to mitigate the impact of bad insurance selection and stabilize the premiums in small-group and individual markets.
However, multiple challenges emerged when the section became a law in 2014. New populations were introduced, cost and risk factors changed, and balanced transfer payments among health plans became increasingly difficult.
As a result, it became increasingly complex for a healthcare facility to properly get paid for their services. However, there are multiple ways to improve risk adjustment workflows.
With these steps, healthcare facilities can be reimbursed properly and on time.
However, before we go into explaining how to improve risk adjustment workflows, let us discuss the steps involved in the risk adjustment process.
Key Steps for Risk Adjustment Workflow
Here are the key steps for risk adjustment workflows:
- Patient identification: The first step is identifying patients with higher healthcare needs. This data is extracted by analyzing a patient’s historical health data, clinical assessment, and past claims information.
- Data Collection: Data related to the patient is collected from various sources, including electronic health records, social determinants of health, and pharmacy records.
- Documentation and coding: Proper diagnostic codes are assigned to each patient’s health condition. Standardized ICD-10 codes are used for proper assessment of a patient’s diagnosis.
- Risk Stratification: Healthcare facilities leverage risk stratification models to categorize patients based on their health risks. Factors these models consider include age, gender, chronic conditions, and other key health indicators.
- Risk Score calculation: Their risk scores are calculated once patients are categorized. Two parameters are considered for calculation: risk stratification and ICD-10 codes. It determines the cost of caring for patients compared to the healthcare facility’s general patient population.
- Submission to payers: The data is then supposed to be submitted to payers, which, in most cases, are insurance providers. This data contains risk-adjusted data, diagnostic codes, and risk scores.
- Payment reconciliation: Insurance carriers—providers—then pay the healthcare facility based on the risk-adjusted data. The goal is to align the financial incentives with the cost of special care a patient receives.
As mentioned earlier, while these steps remove much guesswork, changing data models and emerging new risk factors have created a major issue. To fix those, multiple ways to improve the risk adjustment workflows can be implemented:
Tips to Improve Risk Adjustment Workflows in Healthcare
An improved risk adjustment workflow will not only bring the healthcare facility a fair reimbursement for its healthcare service, but it will also allow the patient to have a good healthcare facility. Below are the tips that can be leveraged to improve healthcare workflow.
Improve the Data Quality
Much of what the insurance carrier finally pays depends on the initial data delivered to them. Healthcare facilities must take extra care to ensure that the data provided is accurate. They can do a complete audit to discover and remove data entry errors, missing information, and inconsistencies in the electronic health records.
Integrated Data Resources
While removing errors from any data is good, the chances of getting fair reimbursements will improve if healthcare facilities integrate all the data sources. It is recommended that data from pharmacy records, claims data, EHR, and other social health determinants be collected to better view the patient’s situation.
Regular Audits
It is of paramount importance for healthcare facilities to engage with regular audits. Regular audit routines can help identify any issues and fix them right away. Getting the right information from the start will prevent the data from snowballing and going from bad to worse—regular audits can help.
Training Programs for Healthcare Providers
Since everything is being updated in risk adjustment workflow management with the arrival of new technologies and new formats, it is important to provide training to those overseeing the risk management workflow process. They must receive more education when it comes to novel risk adjustment methods, coding guidelines, as well as documentation requirements. Yearly training programs will keep healthcare providers abreast of the latest updates.
Utilizing Technologies
Multiple technologies that leverage AI and big data have emerged to simplify risk adjustment workflows. Some of them use natural language processing and machine learning. Healthcare facilities can use these technologies to structure the data they deliver to the insurance carrier. These technologies can also be utilized to prepare clinical notes and improve coding accuracy,
Joining the Clinical Documentation Improvement Programs
Healthcare facilities can learn about and develop their clinical documentation programs to train their professionals. This approach will keep professionals refreshed about the key details, improving the quality of patient data available.
Engaging Patient Engagement Strategies
Since high-risk patients are the key reasons why risk adjustment workflows are there in the first place, healthcare facilities are recommended to use patient engagement strategies. Professionals should make people more aware of their health and give them tips to pursue a healthier lifestyle. It can potentially mitigate health risks.
Investing in Analytics
Healthcare facilities can look into investing in analytics in order to aggregate and analyze large data sets to establish patterns and trends. Transforming the standard operating procedures along with these trends can improve risk adjustment accuracy.
Continual improvements
It is important that healthcare facilities embrace a culture of constant improvement. New risks emerge daily, which is why medical practitioners must never stop evaluating the risks and making adjustments to their workflows.
Conclusion
Risk adjustment workflows in healthcare are put in place to ensure a fair payment. However, changing risks and market conditions require healthcare fasciitis to implement constant improvements.
Improvements to risk adjustment workflows can be in a variety of ways. Maintaining the accuracy of patient data is one, and regular information audit is another. What also helps with improvements is implementing training modules as well as leveraging the latest technologies. When combined, these methodologies can help hospitals mitigate the risk of not getting paid after caring for a patient with special needs.
