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Advance Possibility

Your Goal for 2024: Submit On-Time and Accurate Claims

2024 goals
Meleah Bridgeford
Sr. Director of Risk Adjustment Analytics
December 10, 2023

This article was originally published on RISE on December 4, 2023.

At the start of a new year, it’s natural to think about your goals and objectives. As you contemplate your strategy for 2024, spare a thought for your risk adjustment coding. Without accurate coding, you run the risk of noncompliance, financial shortfalls, incomplete medical records, and a lack of confidence in your data. Now is the time to take steps to build a successful coding program.

But Isn’t It Too Early to Worry About Retrospective Reviews?

It is true that retrospective coding projects traditionally begin in June or July of any given year. However, there is an inherent flaw in this approach. On average, coding projects take about seven months to complete. Therefore, if you start your project mid-year, you will only get one run to ensure your data submissions are accurate and complete.

As an alternative, Episource has been working with some of our clients to test out a different approach to retrospective reviews that appears to bolster coding accuracy. The strategy is to start retrospective coding projects months earlier—in the spring or even as early as winter—to allow enough time to chase additional charts or to perform a second-level review. During the COVID era, CMS created a six-month extension to the standard January 31 final sweep deadline. When Episource analyzed the data to gauge the effect of this extra time and secondary reviews, the results were conclusive. Based on data from 2021 dates of service, we observed:

  • Projects with average risk score lifts as high as 0.591 for charts coded after the January 31 sweep.
  • Projects with average risk score lifts as high as 0.287 for charts coded in a second-level review.

Clearly, there is real value in taking some extra time for retrospective reviews. Plus, it is important to note that those lifts in risk scores directly translate into more accurate diagnoses and medical records, key inputs for delivering better healthcare to patients.

There is one other important advantage to starting retrospective reviews earlier. Providers and their office staff can quickly become overwhelmed when inundated with a large volume of chart requests at once. By starting earlier, you allow a buffer to follow up with the provider’s office, which can make a significant difference in the success of your coding project. Based upon the many retrospective reviews Episource has seen, it is not unusual for a three-month project to only process 70% of records. On the other hand, a six-month project will typically yield results in the neighborhood of 90%.

It definitely pays to start your retrospective coding early. You don’t want to procrastinate with this New Year’s resolution!

Moving Beyond Retrospective Coding

As long as you’re making New Year’s resolutions concerning your risk adjustment program, consider expanding your program. If your organization has historically relied upon retrospective coding, explore prospective and concurrent risk adjustment too. Prospective risk adjustment uses medical records to predict member risk scores at the start of the year, while concurrent risk adjustment uses real-time monitoring to surface sudden changes in patient health. Let’s take a look at some of the benefits you and your members can expect from a more comprehensive risk adjustment program:

  • Early Interventions, Care Coordination, and Proactive Healthcare

Prospective risk adjustment is ideal for proactive, integrated healthcare. At the start of each year, you are assessing the health of members and essentially predicting what healthcare they will likely need. In this process, you will identify the high-risk patients who would most benefit from interventions and coordinate their care.

While a prospective approach sets the stage for expectations at the start of the year, a concurrent approach offers real-time updates throughout the year. Such updates alert providers and health plans of changes in a patient’s health, which allows for immediate adjustments to the plan of care.

  • Financial Predictability

Just as a review of member health at the start of the year allows you to predict care needs, these prospective reviews also allow you to formulate better financial predictions for the coming year. You will gain more visibility into the expected costs for providing care to your membership, a necessity for annual budgeting. Similarly, concurrent risk adjustment provides real-time insight into health changes that could have a significant financial impact.

  • Coding Accuracy

Adding prospective and concurrent strategies to your tool set also gives you additional opportunities to identify and correct coding errors. At the start of the year, prospective risk adjustment will set expectations for what healthcare you can anticipate, giving providers visibility into chronic conditions to treat. Throughout the year, concurrent risk adjustment will help to recalibrate expectations based on the actual encounters providers have with patients. Retrospective risk adjustment provides one last chance to make sure all diagnoses have been treated and documented correctly. This should result in more accurate medical records for patients, providers, and health plans.

Combining retrospective strategies with prospective and concurrent strategies provides the widest possible view of your organization’s risk. You gain insights into past performance that helps inform future needs while receiving real-time updates on changes. This information will help you to offer better care to members and to make better business decisions. Start exploring all of your risk adjustment options now to set yourself up for success throughout 2024.