Risk Adjustment

The Episource Pandemic Playbook

Written By
Erik Simonsen
Chief Operating Officer

2020 will go down in history as a year that fundamentally changed the way we live and work—and how we leverage technology to do both of these things. The healthcare industry in particular has been hit hard by the pandemic, which has forced providers to rapidly find new ways to deliver care and manage risk. While strong analytics are key to any risk-adjustment program, they have become even more critical during COVID-19. The sheer volume of data generated over the past 12 months has provided a unique window into long-standing issues within the healthcare industry that have been brought to the surface by the pandemic.

To make the most of this unprecedented opportunity, we analyzed our data across the many different health plans and provider groups we partner with. The insights we uncovered provided us with a compelling narrative of how to deliver care and manage risk during a pandemic. With this information, we hosted a webinar outlining a playbook of strategies for 2021, outlined below.


A Look Back at 2020: Pain Points & Considerations


Early in the pandemic, we heard from providers that utilization was down by up to 80% in some weeks. When we looked at the data, we found it wasn’t quite that bad for the overall Medicare Advantage population, but we did see major changes in how members engaged with providers.

Chart: YoY Utilization Changes for Risk-Adjustable Providers

Overall, we saw the number of members with no risk-adjustable encounters increase by 50% year over year—a concerning trend from both a documentation and care perspective. When comparing the overall number of encounters that took place in the second half of 2020 vs. the same period in 2019, we saw a 28% drop in Q2 and a 12% drop in Q3. This was in line with what we expected to see based on overall trends. However, when we looked at the number of encounters between PCPs and risk-adjusting specialists, we found that PCP visits had a much bigger drop off and smaller rebound than specialists. This would suggest that members were seeking care for more problem-specific issues as opposed to a whole assessment of wellness.

To better understand this trend, we took a look at visit codes and RAF capture.


Encounter Trends: A Shift in the Nature of Visits


When we analyzed E&M codes, we saw a relative shift from more comprehensive visit codes (L4/L5 visits) to more problem-based codes (L2/L3 visits), reinforcing our initial hypothesis. While PCP RAF capture fell by 38% in Q2 and 26% in Q3, specialist RAF capture was only down 11% in Q2 and then rebounded to +3.3% in Q3.

Chart: YoY HCC RAF Capture

Across the board, this translated to ~3% member RAF decrease, which makes sense given the overall decrease in encounters. During our webinar, we asked participants what they expected the difference in their average RAF score would be for 2020 DOS vs 2019 DOS (as of the end of 2019). In response, 15% said they would be flat to higher, 15% expected to be down more than 5%, and 31% said that they would be down 3-5%, falling in line with the data we’ve seen.


Unemployment & Increased Medicaid Enrollment


When looking at utilization trends, it’s also important to consider the loss of employer-based coverage, which hit older workers disproportionately hard. According to a Kaiser Family Foundation analysis, the unemployment rate among those 65+ quadrupled between March and April 2020, from 3.7% to 15.6%. However, preliminary data shows that total Medicaid and CHIP enrollment grew to 76.5M in August 2020, an increase of 7.4% or 5.3M from enrollment in February 2020. This data tells us that seniors had jobs to cover co-pays and Rx costs. It also indicates that, when there is another primary payor (commercial) or additional coverage, seniors do not need to sacrifice care for basic necessities such as food and rent.


Telehealth & HRAs: Improving Access to Care


It’s impossible to talk about 2020 without talking about telehealth, which played a big part in the shifting nature of encounters. According to HHS, less than 1% of Medicare FFS primary care visits were provided through telehealth in February 2020. By April, that number skyrocketed to 43.5%. While the percentage of telehealth visits has declined from the April peak, it continues to be well above the pre-pandemic levels. Given the drop in PCP visits, health risk assessments (HRAs) have become more important in terms of closing risk gaps and providing access to care. This has been driven, in part, by CMS’ policy, which encouraged the broader use of telehealth by allowing diagnoses captured during these visits to be risk adjustable during the PHE.

Early on in the pandemic, it became necessary for providers to quickly rebuild HRA programs over telehealth. This came with significant challenges, such as limited access to high speed internet and smartphone devices. We also saw a much higher level of no-shows than in-home visits, as well as diagnostic challenges such as the need to conduct an in-person examination or test. Reimbursement has also been a challenge, as many visits are audio only, typically convey less information, and are reimbursed at a fraction of comparative video visits. Despite these growing pains, telehealth has proved to be a vital tool to provide care to millions of people who may have otherwise gone without. At Episource, we found that members were generally very happy with telehealth visits, some of whom had been isolated for extended periods of time.


Medical Record Retrieval: Fluctuations in Provider Responsiveness


To get a complete picture of the overall risk-adjustment landscape, we also analyzed trends in medical record retrieval. What we found was that in the early days of the pandemic, providers were very responsive to retrieval requests. However, as utilization increased, they grew more unreliable. Depending on where the virus was surging, we saw more extensions required, more charts going past due, and more scan technicians being turned away due to COVID concerns. Many risk-adjustment programs also started later than usual, deluging providers with retrieval requests at the end of the year.


A Look Forward: The Episource Pandemic Playbook


With more challenges retrieving records and fewer encounters to code, health plans may well be starting 2021 with bigger gaps than ever before. While vaccines represent a light at the end of the tunnel, distribution has taken longer than expected and overall PCP utilization remains low. To dig deeper into this trend, During our webinar, we asked participants when they expected member engagement and utilization to return to a post-pandemic steady state: 55% said 18 months, 36% said 12 months, and 9% said 6 months. We also asked what kind of planning they had put into place to ensure members are seen in 2021: 50% said they were doing high prospective planning, and 50% said they were doing some prospective planning with similar cohort members as 2020.

These responses, paired with analysis of our own data, emphasize the need to employ strategies such as those laid out in our Pandemic Playbook to navigate the year ahead.


Telehealth & HRAs: One Size Does Not Fit All


As we saw in 2020, a strong telehealth-enabled HRA program will be key in offsetting low utilization. With the Physician Fee Schedule final rule, CMS permanently expanded Medicare telehealth services. Current telehealth allowances (HRA and non-location specific) will continue until the PHE is officially over or until 12/31/2021. Once the PHE ends, CMS will allow HRAs via telehealth only if a provider has previously seen the member and is located within their facility. This legislation is a step in the right direction and emphasizes the need for a telehealth strategy.

In 2020, we found that our clients who implemented a combination of in-home and telehealth HRA options had a much higher success rate. Implementing a device lending program can also help increase success, as we found that over 50% of our MA members did not have a device they could use for telehealth visits. Program efficacy may fluctuate based on things outside of a health plans’ control i.e., new variants, regional spikes, local restrictions, or members simply not showing up. This is why it’s especially important to start programs early and send multiple reminders across various channels to ensure participation.


Encounter Submissions: Leveraging the Extension


On September 18, CMS extended the 2020 payment submission deadline from January to August 2021. With fewer encounters and data utilization opportunities available, we recommend using this time as an opportunity to increase and expand chart capture and do second-level reviews on 2019 charts that have already been retrieved, coded, and submitted to CMS. This provides additional opportunities to capture more codes that might have been missed in the first round of review. In 2019, we ran advanced audits of charts already reviewed by other coding vendors and found 1 to 3% more HCC codes than had been submitted to CMS.

Historically, retrospective programs have primarily chased PCP records. However, with fewer and generally less comprehensive PCP visits in 2020, retrieving specialist records will be more important than ever this year. Beginning 2021 retrieval efforts earlier will also be key. There is a huge difference between starting in May vs. September when smaller plans tend to start. Bigger plans often start earlier and see much higher retrieval rates as a result.


Future-Proof for RADV Audits with Coding


The difficulties of COVID-19 and temporary cancellation of RADV audits in early 2020 temporarily took the topic off of people’s minds. While RADV for 2020 won’t come up for another four years, this distraction could come back to bite health plans eventually. We know that the greatest risk is in codes that were only captured once a year. With fewer encounters, there will be a lot more of those codes in 2020. We also know that there are an increasing number of risk-adjustable codes being recorded through telehealth audio that may not actually be risk adjustable. We suggest using the extension as an opportunity to do reconciliations you wouldn’t normally do in order to make sure nothing has been left on the table between RAPS and EDS.


The Added Value Dual Enrollment


With unemployment in seniors among the highest rate in all age groups, many who were previously employed and were therefore not eligible for Medicaid benefits may now be eligible (dual eligibility). In addition to receiving Medicaid benefits, dual enrollment also reduces copays, coinsurances, and deductibles that many seniors simply cannot afford. Additional support in the way of SNAP and housing assistance may also be needed. The key is to engage with these seniors to see how you can best support them through dual enrollment and other social services. The importance of identifying these seniors and enrolling them in dual or SDOH programs will be critical to bridging the care gap during the pandemic.


Analytics: The Glue That Holds it All Together


Real-time analytics can help pivot programs to be successful in any environment. When looking at our data, we saw evidence that clients who actively managed their risk-adjustment programs saw a much smaller negative change to their RAF scores in 2020. Being able to course correct and direct resources to ensure that members are getting care, codes are getting captured, and RAF/gaps in care doesn’t fall off a cliff—all of these things are enabled by analytics.

Gone are the days of analytics being just chase lists—they have to offer insights into utilization (specialists, PCPs, etc.) and gap closure trends so that you can pivot your prospective programs successfully. Having a good risk-adjustment analytics workflow program that helps segment data, identify RAF opportunities, launch measurable campaigns, and determine compliance risks should you have a RADV audit should be part of your RAF platform.


To learn more about Episource’s comprehensive risk-adjustment platform, visit our website.



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