Having access to complete, updated, and comprehensive patient records has always been a challenge for risk-bearing entities and payers. The ability to have a patient’s full medical history not only is essential for a higher quality of care, but also for identifying and appropriately coding chronic and reoccurring symptoms.
The process of risk adjustment is changing for payers who are using technology in their workflows. This, in turn, leads to better relationships with providers, resulting in a better patient experience and improved levels of patient care.
Challenges of Current RA Workflows
One of the most significant challenges with current or traditional RA workflows is the ability to streamline the medical retrieval process. Many payers have to manage records with incomplete histories, records, and challenges with accessing information about out-of-network claims. There are also issues with medical coding inaccuracies and provider resistance to payer access to this medical documentation.
Providers make this more challenging by using individual systems, forcing the payers to create ways to connect with the provider’s technology. Some providers require only manual retrieval to prevent any changes in the records that can occur. They are concerned that changes may be made as the payer is only concerned about the specifics of the claim, not the ability of the record to pass an audit.
Inaccurate Medical Coding
Providers have faced challenges in keeping up with the shift to risk adjustment. Inefficient workflows and the need to recapture medical diagnoses for a standard look-back period of three years, including the need for some data from the PCP EMR system add to the challenges for medical coders.
Failure to add all required data into the electronic claims process or having insufficient information from the chart on the claim can reduce the quality of patient care.
Provider Participation Problems
Payers often find the biggest challenge is in record retrieval and follow-up from the provider. Providers tend to prioritize acute treatment of patients, which can result in missing follow-ups. Not providing this service or managing chronic conditions can result in disorganization and a lack of understanding about the importance of these services in the risk adjustment model.
ICD-10 coding focuses on providers understanding the importance of the diagnosis and levels of severity. This provides the information necessary to account for high utilization costs for specific diseases and diagnoses. Creating systems that allow both payers and providers to have access to the necessary patient information on a timely basis is a critical factor. It also ensures that the whole patient is being treated and not just the specific symptoms triggering the visit to the provider.
Lack of Efficient Data Retrieval
Data retrieval has not changed much in the last four plus decades, mainly due to the unstructured and disjointed methods of communication between payers and providers. Payers often need to use manual record retrieval, which slows down the process and can overwhelm the staff. Additionally, multiple systems make it difficult for payers to interact effectively with the provider’s system.
The solution is to develop efficient medical records retrieval methods that comply with risk adjustment models. Improving the workflow will benefit payers and also make the process easier for providers. Artificial intelligence to add tools for medical records retrieval combined with access to all clinical data on charts and enhanced provider participation offers the best path to improvement. Combining this with regular visits between the provider and the patient for chronic conditions is another important factor to consider.