Risk Adjustment

3 Tech-Led Retrospective Strategies To Maximize Program Performance Without Provider Abrasion

Written By
Susan Richards Morgan
Director of Risk Adjustment and Coding Education

As we head into 2022 still under the cloud of the pandemic, health plans remain under continued pressure to maximize savings and improve patient outcomes. This is a tall order, considering the fact healthcare spending and regulatory oversight are on the rise and risk scores are on the decline—not to mention the transition from RAPS to 100% EDPS. With all of these factors in mind, it has become more important than ever for health plans to submit complete and accurate health status information to CMS.

While the deadline extension for 2020 dates of service to August 2022 certainly provides some relief for health plans, typical risk adjustment strategies such as medical record retrieval often lead to provider abrasion. As the most recent COVID surge threatens to overwhelm healthcare facilities across the country, there is no such reprieve on the horizon for primary care providers.

So, how can health plans take advantage of the submission deadline extension without putting pressure on already overburdened providers? Here are three tech-led strategies to consider.

1. Bolster Your Analytics Capabilities


A risk-adjustment program is only as effective as the data at its disposal. That’s why it’s critical to ensure data is as accurate as possible before it is ingested by natural language processing (NLP) software or processed to calculate risk scores. A strong risk-adjustment analytics workflow tool should be able to quickly and accurately streamline volumes of data and provide quality assurance. This tool should verify the accuracy and integrity of patient population data, highlight suspected member health conditions that need to be assessed, and offer population management stratifications. By first understanding where your opportunities are, you can then know where to implement additional strategies.

2. Optimize Your Second Level Review With Advanced NLP


Coding accuracy is critical to calculating risk adjustment and budgeting for future patient care. With the submission deadline extension, plans should use this extra time to implement an NLP-targeted second level review to increase coding accuracy. It’s important to find a tool that has been trained on a high volume (and quality) of medical records so it can learn and improve over time. But NLP alone is not enough. Any tool should work alongside expert human coders to evaluate the MEAT of a code and substantiate documentation. This will help improve coding submission accuracy, uncover missed RAF opportunities, and match services to member needs. It’s important to remember that this process is not just about adding codes, but also ‘looking both ways’ to remove unsubstantiated codes.

3. Reduce Data Leakage in the RAPS to EDPS Transition


While this is the last year plans must submit both RAPS and EDPS, it is still critical that they accurately and completely reconcile claims in both systems—otherwise, they will see adverse effects on their risk scores. While RAPS requires fewer than ten data fields, EDPS requires 150, creating more opportunities for errors or missing data. However, an intelligent data management solution can automate and streamline reconciliation of RAPS and EDPS to ensure the complete and accurate submission of encounter data. Reconciling claims in both systems can also help identify if all supplemental data has been accepted, mitigating the risk of paying for something that did not result in an improved outcome.


Episource arms clients with data, tools, and insights to navigate the chaos of the healthcare system. To learn more, join Vinitha Ramnathan, Senior Vice President of Product, Episource, at RISE National 2022, March 7-9, live at Gaylord Opryland in Nashville, Tennessee for a presentation on how to improve patient outcomes and plan performance using a platform approach. Click here for the full agenda, roster of speakers, health and safety protocols, and how to register.



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