There is a growing trend in Health Plans bringing more Risk Adjustment Data Validation Audit and Medical Record Reviews in-house, instead of relying on outsourcing.

Once you have made the decision to move all or some work in-house, ensure your solution and software promotes success in all important areas:

social - How to bring Risk In house

1) Integration of activities end-to-end

  • Maintaining visibility and integration of all activities from provider outreach through coding and over-read is very important.  These projects move fast and work changes hands quickly. It can move forward and backward in the process (maybe even sideways!). Make sure you can track integrations with the medical record chase through everyone who has worked on it.  This will expedite troubleshooting and improve teamwork throughout the project. 
  • Also put your outreach team in a position to be successful on the first outreach attempt, by giving them as much information about the location at their fingertips. This way they can make changes on the fly that will be visible to others on your team in real time.

2) Ability to monitor productivity and quality across all functions, enabling visibility into your progress and challenges

  • The project is so time-sensitive that you cannot afford to run periodic reviews of progress and take inventory of problems and barriers.  Ensure your software solution gives you routine, or better yet--real time visibility to the status of your project.

3) Coordinated outreach

  • Oftentimes it could take several calls and interactions with a location over several weeks to complete the retrieval activities for members seen at that office.  Having a centralized hub for each location will allow the people working that address to see past interactions, statuses of medical record chases at the location, as well as outstanding pended chases that require additional assistance to complete the retrieval. 

4) Managing cost and productivity with automated options for getting Medical Records in the door

  • The two factors weighing most heavily on in-house success is managing cost and productivity. The more work that can be effectively automated in your process, the faster and more cost-efficient it will be.
  • Adding a Quick Response (QR) bar code to the incoming medical records that are faxed or mailed in will allow these documents to automatically associate to a Medical Record Chart chase and be ready for review.  This increases processing speed and reduces the need to manually check-in medical records and associate them to the correct chart chase ID for coding and abstraction.
  • This is similar for Medical Records that are scanned from the hospital, provider office, or clinic. Ideally, you should be able to have these scanned images uploaded and attached to the medical record chase automatically even while you are onsite completing the scan of the medical record or download from an Electronic Medical Record system. This capability will allow efficient and effective linking of the medical record to the member/patient for medical coding review, audit, and coding.

5) Efficient, High Quality Medical Coding and Quality Assurance Over-read 

  • For medical record coding, a good approach is to have the medical record viewer and the data entry tool integrated to a single work space, with key demographic and claim information for the member/patient to ensure that the you have the correct medical record for the member for audit or review. 
  • The ability to highlight and annotate is a great plus and a huge time saver, especially when it comes to quality assurance over-read or if a medical record is selected for Medicare Advantage or ACA Risk Adjustment Data Validation Audit by CMS or OIG.

6) Clearly defined roles and responsibilities

  • Having roles and responsibilities laid out allows managers to efficiently allocate work and manage the workload, and enables communication between teams. It also ensures that no internal inconsistencies occur (OR and MRR) and team members are provided the appropriate level of access.

About The Author

Reveleer is a healthcare software and services company that empowers payers in all lines of business to take control over their risk adjustment and quality improvement programs. The Reveleer platform enables payers to independently execute and manage every aspect of provider outreach, retrieval, coding, abstraction and reporting – all under one single platform. Leveraging its technology, proprietary data sets, and subject matter expertise, Reveleer also assists payers with full record retrieval and review services to support financial performance and improved member outcomes.