Risk adjustment (RA) workflow process in healthcare is here to stay, and even if organizations are slowly catching up, there are a lot of gaps that need to be closed for it to become more efficient. There are several ways to help providers catch up and improve their workflows that will help their health outcome management and, by and large, improve their RAF scores.
Before we talk about how to improve RA workflow processes, let’s see at a glance some of the limitations of the old risk adjustment workflows according to reports we see at Inferscience while working with healthcare providers.
Limitations of traditional RA workflows
Inefficient medical record retrieval
Healthcare providers feel very frustrated using medical records generated from risk adjustment retrieval projects. According to them, “it feels like throwing everything in the air and hoping things land correctly.” This is because of several factors: the lack of involvement and commitment from the healthcare team and the barely surviving process of manual RA coding.
Inaccurate data coding
Some of the complaints we hear at Inferscience from healthcare providers, previous to using an HCC Coding software tool, is the added burden of coding. Coding is a complicated process because it means having to sort through the ICD-10 codes that are unstructured and disjointed, not to mention the obstacles they face from using incomplete and carelessly reported medical histories.
Inadequate involvement of the healthcare team
Because the healthcare providers feel that ICD-10 coding is like using a method that is buried somewhere that would take more than an expert to find, this adds to their lack of involvement and participation in the RA workflow process. Not to mention the technical issues providers encounter as the team migrates to a new process.
Now that we have named some of the limitations of traditional RA workflows let’s enumerate the merits of using new technology-optimized reporting tools in implementing risk adjustment systems.
Benefits of Reporting in RA workflows
Tools like the HCC Assistant not only make HCC medical coding simpler; they also eliminate the obstacle of guessing who is utilizing the tool. With customized utilization reporting, the HCC Assistant gives admins daily reports that can be seen by each provider to review their own results or everyone on the healthcare leadership team. This process raises the satisfaction and ease of use for providers, therefore, earning their participation and accountability.
Team leadership skills can be strenghtened by having the right information to keep the team accountable for their HCC utilization and leaders can also get a glance of who is collaborating with the overall goals and workflow.
With better team leadership, accountability, and participation, all healthcare providers will have ease of practice over time. These factors will influence the team’s performance contributing to better RA scores.
The Future of RA Workflows
A primary key in the future of using automated and/or assisted RA workflows is the team of providers working together consistently and committedly. Here are some keys to the future of RA workflows:
Interoperability in healthcare
As the healthcare industry landscape rapidly changes, intensified by the Covid-19 pandemic, all stakeholders need to cooperate to make the system more interoperable. We all know that post-pandemic, patients have now become advocates of greater and easier access to their medical records, putting much emphasis on privacy.
On the other side of the spectrum and as the sharing of health data increases, everyone on the provider side needs to keep up with the demands by emphasizing everyone’s commitment to first; provide quality care and second ensure access to complete and accurate medical records.
Consent and data segmentation
On top of the need for interoperability, informed consent is crucial to make patients well-informed and become partners in the responsibility of their health management. Data, on the other hand, is the sole responsibility of the providers making sure they are handled with utmost confidentiality yet, not compromising availability to everyone in the care of the patient.
21st Century Cures Act
In March 2020, a big step forward was made as the 21st Century Cures Act was put together by the Office of the National Coordinator (ONC) for Health Information Technology (IT). ONC, together with the Centers for Medicare & Medicaid (CMS), finalized the implementing rules for the Cures Act requiring select payers, health care systems, and health IT vendors to provide patients access to their data, primarily through Fast Healthcare Interoperability Resources (FHIR) Application Programming Interface (API). The Cures Act is a significant advancement that enables patients to easily access their medical records using any app of their choice.
In Conclusion, Collaboration as KEY
It would be an understatement to say that all stakeholders should collaborate to make these advancement efforts become a success. The building blocks and key drivers were the frameworks for consent and segmentation, coupled with a strong technology structure.
In conclusion, although many of the provisions in the Final Rule of the Cures Act are highly technical and are powered by Health IT programmers and developers, physicians and the rest of the healthcare providers need to comply with making migration into this system smooth for everyone. Just as important is to keep IT systems and the team updated with the latest requirements and implementing rules which also happens to be the qualifications of most Medicare Quality Reporting and Promoting Interoperability programs.