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Advance Possibility

How ACO Risk Adjustment Analytics Can Improve Care, Close Gaps, and Boost RAF Scores

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July 1, 2020

Yes, this is a challenging year for accountable care. Yes, there is still room for guidance from the Centers for Medicare & Medicaid Services (CMS) on how to sustain the Medicare Shared Services Program (MSSP). And, of course, yes, Accountable Care Organizations (ACOs) have countless factors at play that are making, and are going to make, risk adjustment challenging.

However, this year is not over, and there are many things well within your control if action is taken. One such action is to incorporate analytics that allow for Hierarchical Condition Category (HCC) gap targeting. If employed meticulously, analytics optimize risk adjustment for ACOs. Risk bearing organizations can track 2019 risk adjustment performance while creating 2020 prospective plans to reduce gaps in care, document conditions, and demonstrate proper prevention and treatment.

Accountable Care Organization Analytics

ACO risk adjustment analytics provide everything necessary to decide the best path forward. Risk adjustment departments can determine how best to approach provider education for closing gaps and evaluate the effectiveness of current wellness visits in closing gaps.

Improved Targeting

One of the primary challenges ACOs face with risk adjustment is patient targeting. ACOs tend to have patients who see doctors outside of the ACO, and those doctors likely don’t have an incentive to provide data for risk adjustment. That’s why a target list, or a list of patients who have multiple chronic health conditions for example, is vital. A target list will use a combination of how long a patient has been a beneficiary and the practices they’ve been to within the ACO, which helps providers improve their risk stratification and population management.

Episource’s ACO analytics solution can take in raw data and Claim and Claim Line Feed (CCLF) data to ensure accurate reporting and streamline the risk adjustment process. Analytics with a filtering logic that specifically targets the beneficiaries the ACO needs to track will ultimately make their benchmark more accurately reflect the risk they’re taking.

A strong filtering logic prioritizes chases of participating providers, ensuring that those providers taking risk have a stake in providing and updating records for beneficiaries in the ACO.

Increased Coding Accuracy and Care Gaps Closure

Another barrier that ACOs face is the limited time they have to work with their doctors to correct claims. All of the medical claims clearinghouses have the same rules — usually 365 days from the last decision to make an adjustment. For ACOs, this isn’t a lot of time to correct a claim and submit to the regional Medicaid and Chip Program (MAC). If ACOs are not proactive about closing gaps and finding new opportunities, they’ll have less say about their risk adjustment scores for the prior year.

Therefore, working with a risk adjustment analytics partner can help ACOs identify missing HCCs, close gaps, and better manage care for patients, both retrospectively and prospectively. With analytics, ACOs get access to the discrete data that can increase code capture, identify gaps in HCC capture, and target patients by HCC gap opportunity. Analytics can also help identify HCC gaps that providers weren’t able to close and use the data to prospectively generate a patient gap letter to capture diagnoses at the next visit and better manage care.

Provider Education and Improved Documentation

Some partners offer solutions such as coder education programs, which can include one-on-one support to help providers with coding and documentation.

They can also identify dual eligible patients to provide care and close gaps. With this support, ACOs can find opportunities to improve their risk adjustment factor (RAF) scores.

With a flexible analytics solution, ACOs are able to customize programs for their populations and create micro-strategies rather than forcing their RAF programs into a box that doesn’t fit their objectives. For example, ACOs can evaluate the effectiveness of annual wellness visits on closing gaps and hone in on those providers where gaps remain open after visits. ACOs that have partnered with Episource have seen gaps in care closures increase between 20 to 50% for the target population (a subset of the entire population). This however brings the entire population up to the threshold of 3%, maximizing value and conducting a lower amount of chart audits.

An ACO risk adjustment program isn’t only about raising RAF scores, but also improving care. If the right codes aren’t captured, risk stratification is impossible. For example, if an ACO has a lab report for type-2 diabetes, but not a diagnosis, running analytics can identify the care gap and support a proactive solution to provide care and prevent additional comorbidities.

Funding and Operations

Analytics supports ACO funding and operations because it adds clarity to the weighted benchmarks, takes into account their risk scores, and helps to ensure an optimal ROI. For example a 3% increase in RAF above the benchmark can mean the difference between reaching the minimum savings rate or not.

With the right analytics partner, ACOs can get a comprehensive understanding of their RAF scores and how it helps them meet their benchmarks, while at the same time investing in risk adjustment at an appropriate level.

For overburdened payers and providers, Episource helps close gaps in healthcare by marrying expert guidance with an end-to-end risk adjustment platform. Learn more about Episource Analyst and other solutions at Episource.com.