RISK ADJUSTMENT MICRO-STRATEGIES - JASON MCDANIEL VICE PRESIDENT, RA & QUALITY HEALTHCARE PARTNERS - EPISOURCE
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Risk Adjustment
Micro-Strategies
Sujata Bajaj
SVP of Product
Jason McDaniel
Vice President, RA &
Quality Healthcare Partners
Introduction
Micro-strategy Definition
Risk Adjustment micro-strategies reflect
smaller, laser-focused programs that are
intended to capture typically missed RAF.
Additionally, these programs are designed to
account for the intersection of cash-flow and
sweeps deadlines.
episource.comGaps Guide Your Strategies
HCC Gap Closure
HCC Gap Reason Solution HCC Gap
Identification
No Date of Service Member Outreach, Provider Outreach, Health Risk Assessments
No Diagnosis HCC Gap Letters, Analytics, HCC Suspecting, Health Risk Assessments
Strategy
Poor Documentation HCC Gap Letters, Health Risk Assessments To Close
Poor Coding Retrospective Chart Audits
Execution
Poor Submissions epiEncounter + Project
Management
episource.comRAF Management is a Large-Scale
Optimization Problem
What strategies do I deploy, for which population, with the budget I have?
Suspect Year Suspect Type HRA Status DOS Count Provider DOS Provider YoY Time of Year Audit Status
YoY Suspect Provider No DOS Provider YoY Chart Audit
Current Year HRA Capturable DOS = 0 Q1
Rate Low Recap Rate Low Complete
Not HRA Provider No DOS Provider YoY
Prior Year Clinical Suspect DOS > 0 Q2 No Chart Audit
Capturable Rate High Recap Rate High
Q3
Q4
Programs
Chart Audit - $25 Targeted Recode - $7 HRA - $350
Gap Letter- $50 Member Outreach - $35 Do Nothing - $0
episource.comBasic Risk Adjustment Strategies
There are typically three pillars of a Risk Adjustment program:
Retrospective Prospective Provider Recently a fourth pillar of
In-home health
Chart outreach/work Education assessments (aka Health
Reviews with providers Risk Assessment or HRA)
and members
episource.comWhy Micro-strategies?
Basic strategies close a good number of gaps and
they help with recapture rates.
They keep the status quo
Often fail to keep up with model changes
Don’t uncover data irregularities
Fixing these is often low-hanging fruit (e.g. >3 DOS).
Broad strategies and precise, micro-strategies are both necessary for successful Risk Adjustment.
episource.comWhy Micro-strategies?
Additionally, timing Better timing leads to Micro-strategies find and
is a key revenue sooner rather close opportunities and
component. than later. develop a more
consistent cash flow.
episource.comBuilding a Risk Adjustment Team
Clinical Leadership IT Leadership
• RA & Quality Medical Director • Director of IT
• Affiliate Medical Director • IT Project Manager
• APP Medical Director
Decision Support/Analytics
• Data Warehouse Manager
Operational Leadership • Decision Support Analysts
• Vice President, RA & Quality
• Vice President, Operations
• Operations Directors, MG & Affiliate Coding
• Quality Manager
• Provider Relations • Medical Group Risk Coding Manager
• Affiliate Provider Coding Manager
episource.comOperations
Clinical Team Chart Reviews Point of Care Solution
• RNs & LPNs • Ease of Use
• Physician Support • Incorporate All Information
• Vendor • Prospective Reviews
• Claims Data
• EHR Data
Medical Coding • Suspecting Logic
• FFS vs. Risk Coders • Quality Measures
• Reporting
• Provider, Clinic, and Payer specific
Software/Analytics • Prevalence Rates
• Provider Agree/Disagree Rates
• Natural Language • Visits/Appointments
Processing/Machine Learning
• Clinical Correlations
episource.comAnalytics
Nitrate without Prevalence Rates of
Diagnoses of Angina HCC 18 vs. HCC 19
• HCC 88 (RAF – 0.135) • RAF Difference 0.197
• 496 Patients • Owned Provider Group
• Physician to Physician Education • < 5% prevalence rate of HCC 19
• Reconcile Medication Lists
Morbid Obesity
• HCC 22 (RAF - 0.250)
• BMI ≥ 35 with Comorbidities
• BMI ≥ 40
• 1,992 Patients
episource.comAnalytics
Major Depressive Major Depression
Disorder
• PHQ2/PHQ9 • HCC 59 (RAF – 0.309)
• F32.0 Single episode, mild • F32.9 without HCC 59
• F32.1 Single episode, moderate
• F32.2 Single episode, severe without psychotic features
• 1,349 Patients
• F32.3 Single episode, severe with psychotic features • Oncology
• F32.4 Single episode, in partial remission • Prevalence is 2 – 4 times
• F32.5 Major depressive disorder, single episode, in full remission greater
• F32.9 Single episode, unspecified • Create Coordination of
• F33.0 Recurrent, mild Care
• F33.1 Recurrent, moderate
• F33.2 Recurrent severe without psychotic features
• F33.3 Recurrent, severe with psychotic symptoms
• F33.40 Recurrent, in remission, unspecified
• F33.41 Recurrent, in partial remission
• F33.42 Recurrent, in full remission
• F33.8 Other recurrent depressive disorders
• F33.9 Recurrent, unspecified
episource.comProvider Education/Targeting
60%
56.51%
Diabetes - 18 - Diabetes with
Chronic Complications
50% Diabetes - 19 - Diabetes
without Complication
Heart - 85 - Congestive
40% Heart Failure
33.82% Heart - 88 - Angina
Pectoris
30%
29.11%
27.21% Heart - 96 - Specified Heart
25.70% Arrhythmias
24.47%
23.18%
19.43% Lung - 111 - Chronic
20% 18.80% Obstructive Pulmonary
Disease
14.66% 14.52% Metabolic - 22 - Morbid
12.61% 11.66% Obesity
9.98%
10% 7.16% Psychiatric - 59 - Major
4.73% 5.15% Depressive, Bipolar, and
3.61% Paranoid Disorders
Vascular - 108 - Vascular
0% Disease
Doctor A NP B
episource.comRAF Playbook
From analytics we We create campaigns for By dividing these into micro-
generate a RAF each micro-strategy to strategies it’s possible to
playbook with execute and then measure execute each based on value
strategies the success and complexity
episource.comRAF Playbook Example
Segment Description of Members in Segment Count Current RAF Projected RAF Post RAF
1 No visit but at least 1 HCC suspect in 2019 554 0.546 0.959 1.505
2 3+ visits with No HCCs in 2019, but 1+ HCCs in 2018 1,278 0.479 1.207 1.686
3 Morbid Obesity (HCC022) is YoY suspect 1,130 1.312 0.244 1 1.556
4.1 Diabetes is down-coded (Higher HCC is suspect) 484 1.177 0.200 2 1.377
4.2 Vascular Disease is down-coded 107 2.579 0.088 3 2.667
5 PCC (Payment Condition Count) possibly > 5 4,308 1.675 1.242 2.917
6 1+ HRA Assessable suspects (Tier 1) 4,247 1.586 1.546 3.132
1 HCC022 (Morbid Obesity) Community Non-Dual Member RAF = 0.244,
2 RAF for HCC018 (Diabetes w/ Chronic Complications) is 0.197 higher than HCC019 (Diabetes w/o Complications).
3 RAF for HCCC107 (Vascular Disease w/ Complications) is 0.095 higher than HCC108(Vascular Disease)
episource.comEngage Non-Compliant Members
An annual analysis of members without an annual wellness visit
Goal:
Create a new year AWV that ensures that these 5-7% of
In most well-oiled plans, the range is members get in to see the PCP or complete an in-home
5-7% of “persistently non-compliant” visit by June 30th of the new calendar year.
members.
Revenue Flow:
This may lead to possible claims
expense surprises, but also leaves a The June 30th 2020 DOS cut off can and should be submitted to
lot of opportunity. CMS for September 2020 sweeps, ensuring revenue updates for
Jan 2021. Plans often wait until the end of the year to consider
members non-compliant.
This means revenue won’t be seen until Jan 2022.
episource.comCombining Gap Letters and AWVs
Gap letters can increase the quality of
care and improve documentation.
Effectively addressing each of a patient’s active and
suspected conditions becomes even more
important among populations that are less likely to
see their provider on a regular basis.
Providers will have insights that enable them to
provide the highest level of care.
episource.comScreenings
PHQ – 2 & PHQ – 9 Peripheral Vascular Disease
• PCP and Specialty Providers • ABI/QuantaFlo
• Prevalence • Over age 65
• Owned MG – 19.03% • Over age 50 with history of smoking
• Affiliate Providers – 13.51%
• Oncology
• Prevalence Rates are 2 – 4 times greater
• Create Coordination of Care
Lung Cancer Screening
• Current Smokers
• Quit Smoking within 15 years
• Atherosclerosis
• Emphysema
episource.comScreening Results
80.00%
PAD Results
70.00% 67.70%
60.00%
Pad Result Total Count
50.00%
Negative 12,952 67.7%
Positive 6,179 32.3%
40.00%
Total 19,131
30.00%
20.00% 15.27%
9.64%
10.00% 5.28%
2.11%
0.00%
Normal Mild Moderate Significant Severe
Negative PAD Positive PAD
episource.comAdvanced Coding Audits
Providers typically document 80% of codes correctly, meaning 80% coding accuracy yields no ROI
Average chart contains 100 codes
Coding accuracy of 95% Provider Dx obvious in
yields 75% of the value, chart but have no value
leaving 25% of a medical Admit DX
record’s value. R531 Weakness
80%
Primary Diagnosis of Dx are
Correctly 80% Accuracy: 95% Accuracy:
R5383 Other fatigue 80/80 prov. codes 80/80 prov. codes
Captured by
Advanced coding audits Provider 0/20 new codes 15/20 new codes
use NLP and data to Primary Diagnosis 0% of value 75% of value
R079 Chest pain, unspecified
review medical records E785 Hyperlipidemia, unspecified
that deliver the highest I5032 Chronic diastolic (congestive)
degree of quality and heart failure
accuracy. 20%
New Dx w/ value are more of Dx are New
easily overlooked
episource.comAdvanced Coding Audits
Find value in charts, even those previously coded with high accuracy
Charts Claims RAF $ Increment $ / Chart
Plan Increment Notes
After 1LR and 2LR
National 1,773 Yes 9 $87,562 $49 coding by two
different vendors
Regional NE 857 Yes 22 $397,648 $464
Regional MW 5,000 Yes 73 $701,021 $140
7,630 104 $1,186,231 $155
A 1% quality increase can have a ~$30+ difference in revenue
episource.comThe 2020 Alternative Payment
Condition Count (APCC) Model
RAF changes due to APCC model
Using the PY 2018, 2019 and
2020 model comparisons we
see a decrease of RAF on
average by 3.6% w/o
normalization.
We’ve applied the new
coefficients outlined in the April
1, 2019 ruling.
episource.comThe 2020 APCC Model
PY 2020 is net negative in RAF year over year
A look at all three things that affect RAF scores:
1. 2. 3.
Model Changes Normalization Coding Intensity
Factors
net negative net negative no change
weighted 3.6% weighted year over
3.15% year
Total net negative change on average = (6.65)%
episource.comThe 2020 APCC Model
Member Vignette:
72-year-old female,
Community non-dual
member
episource.comReconciliation
Electronic Health Record (EHR) CMS/Payer Information
• Progress Notes • MMR, RAPs, MOR, Eligibility, MAO-002, MAO-004
• Encounter/Submission • Suspecting Algorithm Output
• Concurrent Coding • Standard Metrics
• Coding Guidelines • Office Visits
• Risk vs. FFS Coders • Physical Exams
• HCC Capture
Billing/Practice Management System Clearing House
• Edits • Submission Accuracy
• Risk vs. FFS
episource.comVendor Partnerships
Concurrent Coding Embedded NPs
• Off-Shore supplemental coding • Under Performing MG & Affiliate Practices
• Primary Care and Cardiology • Improve access
Retrospective Audits/Coding In Home Assessments
• Affiliate Record Retrieval • 3k – 6k Visits Per Year
• Medical Coding Team • Focused Population
• Secondary NLP/Machine Learning • Non Value-Based Care Focused Affiliate Providers
• Increased Access for Medical Group Providers
Prospective Reviews Mobile Clinic
• Supplement to Internal Team of CDI RNs
• Create Geographic Events
• Must complete 70k reviews each year
• Shopping Centers, Gyms, etc.
episource.comKey Takeaways
Risk Adjustment Team Vendor Partnerships
Creation/Building • Difficult to Build Internal Team
• Specific Expertise
• Idea Oriented
• Metric Accountability
• Passion
Analytics
• Basic Metrics
• Provider & Clinic Membership
Screenings • Re/suspect Evaluation
• Members without an Office Visit
• Quality of Care • Members without an AWV
• Disease Prevention/Utilization • RAF
• Risk Adjustment • Margin Identification
• Disease Prevalence
• Expand Denominator of Conditions
episource.comKey Takeaways
Create & Measure
campaigns from your
RAF playbook
Measuring is critical
to making repeatable
campaigns and
course correcting
from year to year
episource.comKey Takeaways
Cash flow review Create RAF Playbook Your micro strategies will
Revenue now better than This allows you to use not be the same each year.
revenue later, close gaps in your analytics to create Good analytics will help you
the first half of the year to pods of executable drive the best value adds for
see better cash flow than strategies your RA program
waiting in the latter half of
the year.
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