June 22 2017 | 0 Comments | 241 reads Average Rating: 3

6 Ways to Bring Home Risk Adjustment and Quality Gold

by EXL Healthcare in Risk Adjustment

Have you ever watched a “rowing eight” race? Eight athletes. One boat. Pulling in the same direction. Using the same sized oars. Moving in perfect synchronization. All with one goal in mind: crossing the finish line before their competitors. It’s pretty much the ultimate illustration of teamwork.

Payer and provider organizations should take note. If they can create similar alignment, they might just end up claiming risk adjustment and quality gold. During a Webinar entitled “Rowing Together: Fostering Payer-Provider Collaboration to Improve Risk Adjustment & Quality Programs,” my colleague Rachel Hall explained why it is so important for healthcare payers and providers to get to know one another, while I outlined how these healthcare organizations can create the consensus that every winning team needs by adopting the following best practices:

1. Assess the current state of data transparency. Providers and payers must share their data – and then confirm that they are on the same page. Doing so enables providers and payers to identify and rectify any discrepancies. For example, SCIO recently worked with a health plan that shared data with physicians during an on-site meeting. During this exchange, one physician recognized the name of a member and remembered assessing a certain condition. So, he questioned why the payer data indicated a care gap. When SCIO informed the payer of the discrepancy, the health plan’s IT manager was able to pinpoint the breakdown in the claims data extraction process. In essence, while the plan had the data, they didn’t know that it was not being sent to the Centers for Medicare & Medicaid Services. By correcting this oversight, the plan was able to recover about $7 million.

2. Embrace what’s ahead. Retrospective analysis involves reviewing charts with the goal of finding missing data – and determining what might have gone astray. Prospective review, however, involves identifying what can be done to ensure that all needed data is collected in real time. When prospective strategies are used, physicians are more likely to be prompted to address certain conditions such as congestive heart failure (CHF) or bipolar disorder, for example.

To most expediently move toward goals, a leader needs to take the helm.

3. Know your own strength. Always set manageable, realistic goals. For example, when plans and providers are just starting to work together, it makes sense to simply look for members who are not seeing their doctors – and perform some outreach to help assuage the situation. As organizations become more sophisticated, though, they should start to analyze care gaps with respect to specific hierarchical condition categories (HCCs) such as CHF or chronic obstructive pulmonary disease (COPD).

4. Lean on a champion. To most expediently move toward goals, a leader needs to take the helm. Medical directors make good champions, as they can easily address both clinical issues with doctors and financial issues with executives.

5. Put together a diverse team. Remember, to reach goals, it’s essential to rely on a team that includes representatives from both large and small physician groups.

6. Give it time. Don’t expect to reach the finish line in just weeks. What’s important, however, is staying on course. To do so, make sure to establish a workable cadence, whether that means meeting quarterly, monthly or weekly.

These are some of the best practices that your organization can leverage to meet its goals. Can you think of any others?

Rate this Article:

Average: 3 (2 votes)

EXL Healthcare

Log in to post comments



Arun Rangamani
VP, Payment Services Delivery Leader

Ben Steverman
Chief Technology Officer

David Hom
Chief Evangelist

Jodi Siegel, MSHI, BSN, RN (Guest Author)
Director, wellness and care management

John Pagliuca
Vice President, Life Sciences

Lalithya Yerramilli
VP, Healthcare Solutions

Lesli Adams, MPA (Guest Author)
Director of Population Health Strategy, Oracle Corporation

Linda Pantovic (Guest Author)
Director of Compliance & Risk Adjustment, Scripps Health Plan Services

Mark Feeney
Life Sciences Consultant

Monique Pierce
Vice President, Business Optimization

Nayfe Faillace
Chief Compliance & Privacy Officer

Nicole Stec (Guest Author)
Senior Well-Being Manager, Banner Health

Priyanka Rajkumar
VP - SCIOXpert and Solutions, Analytics

Rena Bielinski
SVP, Strategic Accounts

Rodger Smith
SVP, Payment Integrity

Rose Higgins
SVP & GM, Data and Analytics

Subha Vaidyanathan
VP, Technology and Data Management

Taryn Bevilacqua
Compliance Director


Sign up to receive the latest SCIO news & insights, industry updates, event updates and more, right in your inbox.