Ask health plan executives about chart audits and you are certain to hear a collective groan. They are labor-intensive, quite expensive and a significant pain point for physicians. And it’s seemingly become an annual event with no end in sight. Until now.
Advanced analytics with clinical integration offers health plans and providers the ability to use technology to replace chart audits.
As payers know, chart audits have served an important function. Health plans do them – and physicians reluctantly participate – because significant revenue is at stake. Member health is too.
In short, health plans contract with companies that send nurses and medical examiners to visit participating provider offices and review member charts. The nurses are looking for opportunities to increase the plan’s quality scores and revenue – and the provider’s quality and revenue too – by closing care gaps connected to HEDIS® measures and Medicare Star ratings and improving the documentation of the complexity of a member’s care known as the Hierarchical Condition Category (HCC) model. It also includes a Risk Adjustment Factor (RAF).
The easiest way to understand the implications for accurate coding is by example: George, a 66-year-old male enrolled in a Medicare Advantage plan.
George’s demographic information yielded a risk score of 0.288 and reimbursement to the health plan of $12,880. Together, his risk score totaled 1.55 for a payment of $15,500. George was diagnosed with heart failure in the previous year, but since it was under control, the physician did not document it in the current year (or did not document it properly). Therefore, the code could not be maintained, reducing George’s risk score by 0.368 or $3,680.
By appropriately adding condition severity, complications and co-morbidity diagnoses that apply for George (mild depression, diabetic neuropathy and diabetes mellitus/heart failure interaction), his risk score increased by 0.762 or $7,620. In total, accurate coding led to a payment of $26,800 for George’s healthcare, an increase of $11,300, all by just accurately representing the complexity of George’s health.
Estimates suggest proper coding would lead to a gain of approximately $2,000 per Medicare Advantage member per year.
From a member perspective, complete coding and proper reimbursement give health plans and providers the resources to provide appropriate services. It also means members with complex or chronic conditions like George are prioritized for additional services.
It may be tempting to think of George as an extreme example, but we know more than 25 percent of Medicare beneficiaries have diabetes, and diabetics frequently have comorbidities:
- 71 percent of diabetics have hypertension
- 65 percent have abnormally elevated cholesterol or fats in the blood (dyslipidemia)
- 28.5 percent have retinal disease (retinopathy)
- 44 percent of kidney failures are due to diabetes
- Heart attacks are 1.8 times higher in the diabetic population
This example illustrates the financial and population health upside of proper coding, but also the inherent complexity to complete coding. This increasing administrative burden typically falls to physicians and their staff, supplemented by health plan chart audits, which together contribute to increasing levels of physician frustration and burnout.
Advanced analytics with clinical integration is the solution for health plans and their provider networks.
The most robust advanced analytics platforms integrate 25 or more sources of information, including clinical data, demographics and psychographics to create a 360-degree view of each member. Just as importantly, the plan and providers need to work in the same analytics platform and seamlessly share timely information about members, and the information must be integrated into the physician’s existing workflow – all of which is now possible.
The integration of clinical and claims information coupled with analytics and sophisticated algorithms leads to the discovery of codes that existed in the previous year, but not the current one, such as George’s heart failure. The platform then prompts the provider to add this information. Similarly, advanced analytics tools proactively identify members at risk for developing a range of medical conditions as well as produce suspect codes for frequent co-morbidities like George’s mild depression.
These inherent capabilities of the most robust analytics platforms also lead to better performance on HEDIS® measures and an increase in Medicare Star ratings. The continuous, year-round monitoring in a shared tool means members are constantly identified for critical preventive services, eliminating the end-of-the-year scramble, reducing costs and increasing satisfaction.
Present health plan executives with advanced analytics with clinical integration to replace chart audits, and instead of a groan, I believe we will hear a collective sigh of relief.
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