Pretty much anyone within the Risk Adjustment world talk about similar topics of concern: the need to accurately capture and protect revenue, proactively assess and manage member health, contain cost, and improve quality. All while the regulatory landscape becomes more demanding and risk adjustment becomes more commonplace and varied. For example, submission of corrected claims are gaining greater scrutiny by regulators, as a means to identify fraudulent billing practices.
Historically, retrospective chart reviews were most commonly deployed for influencing risk scores and improving revenue. This look-back into a member’s medical record has often been 12 to 18 months beyond the encounter date. The delay in correcting the submission of data to a plan’s regulators contributes to a wide variability in risk scores and ultimately in reimbursement.
Regardless of which concern one focuses on, the need to submit COMPLETE and ACCURATE data in a TIMELY fashion is the recurring theme. Plans are compelled to remedy data (and document) lags. The sensible solution, then, is to continuously review medical records as medical encounter data becomes available.
This process essentially boils down to continual reviews focusing on recent encounters as driven by the encounter data (which is about as ‘concurrent’ as it gets). The triggering event for a concurrent RA review is driven by a claim submitted from a provider so abstraction of the medical record can be timely. In turn, this enables a host of follow-on activities, member outreach, provider education, and, more accurate and complete submissions to regulators through further integration with the plans EDPS processes.
So concurrent RA reviews enable a plan to better balance the information requirements of the regulators and to establish greater controls on revenue generating activities and the many related activities.
Implementing a concurrent review process can be tricky and costly. Read about some key considerations in our next blog.