Value-based programs reimburse providers based on the delivery of high-quality care to their patients rather than the quantity of care provided (fee for service). As Medicare Advantage (MA) enrollment has risen 10% per year over the past two years, value-based reimbursement across your organization may also see an uptick. In 2021, more than 26 million people were enrolled in Medicare Advantage plans (43% of the total Medicare population) and accounted for $343 billion (or 46%) of total federal Medicare spending. Preparing your organization to help manage this growth is critical to delivering ongoing high-quality care to your patients and receiving accurate reimbursement.

Accurate, specific and consistent International Classification of Diseases (ICD-10-CM) diagnosis code capture and submission by the treating providers at the time of the encounter visit drives the patient-centric hierarchical condition category (HCC) model. Any active current and/or chronic conditions inclusive in HCC models will need to be assessed, managed and claimed year after year. Underreporting conditions may result in a loss of revenue, while inaccurately over-reporting may pose a compliance risk to your organization.

HCC diagnoses represent the metaphorical hidden “suitcase” that your patients bring with them on each visit to your organization. They’re contained in problem and medication lists as well as symptoms that may be related to active or chronic conditions being managed encounter after encounter – year after year – by your providers. They should be accurately and consistently capturing this information throughout the year, and in subsequent years, in their clinical documentation and coding practices. Making sure your providers are accurately and compliantly performing these activities is critical for maintaining quality data across your managed care population.

The keys for a successful risk adjustment program? Your people working in tandem with solid processes powered by innovative and measurable technology and reporting that help capture these chronic conditions.

People: The need for specialized and certified talent

Our PwC team can help assess, design and implement risk-based coding and documentation programs to address your organization’s value-based reimbursement (VBR) needs. PwC’s risk adjustment coders and nurses support clients in a variety of settings with the development of compliance-based risk adjustment coding and documentation programs. From initial design, redesign and implementation across your organization, we’ve developed programs from the ground up across health systems to help bridge the gap among patient, provider and data across your enterprise and patient population.

Our PwC HCC coding and documentation team can help educate and train your internal coding team and has assisted in the onboarding and staff development of CRC coders to hit the ground running. And if you have resource constraints, the PwC VBO (Virtual Business Office) team can recruit and help identify the credentialed risk-adjustment coding and documentation talent to support your needs. Our risk-adjustment coders and clinicians will onboard and educate your team on standard industry-leading practices and compliant risk-adjustment guidance. We’ll also train your team on how to identify, prioritize and deliver provider clarification opportunities.

Robust processes: If you fail to plan, you plan to fail

PwC’s enabled risk-adjustment professionals can help your organization develop robust risk-adjustment workflow processes, policies and procedures, clarification templates, key performance indicators/scorecards and enterprise reporting and controls to help meet your program goals.

Our Risk Adjustment team performs ongoing compliance assessments to monitor your provider coding quality evaluation process and offers a mechanism for quality and compliance reviews along with provider educational strategies. Using the people, process and technology transformation approach, our team has supported healthcare organizations for more than a decade by helping to manage their risk-adjustment populations and promote compliance while helping increase HCC capture rates.

Technology

We can help design and build a solution that integrates with your electronic medical record (EMR) and reimbursement systems to help accurately and compliantly capture HCCs. Leveraging your revenue cycle reports and third-party technology applications to automate processes, we can help build VBR reporting including a robust pre-visit encounter (prospective) coding and provider clarification process, post-visit encounter (retrospective) coding and provider clarification process, and established key performance metrics (coder and provider performance metrics/scorecards).

Retrospectively, we offer a coding compliance software solution, called SMART, that can assist your organization identify high-risk HCCs in your inpatient Medicare Advantage and Commercial Populations.

Our SMART inpatient tool has helped many of our clients in the market for 30 years. It can identify many risk adjustment conditions by flagging a diagnosis code if it’s an HCC, or a case where the coding and documentation may be at risk. Coders can then review, make sure that codes or cases are confirmed in the record and get a holistic picture of that patient during the encounter. Our SMART tool has more than 600 flags that identify current conditions, and users can customize and build their own flags to identify coding and documentation opportunities and validate prior to billing.

Improving healthcare experiences

While the healthcare market is being disrupted for patients, providers and payers – that’s not necessarily a bad thing. A human-led, tech-enabled risk adjustment program can help improve patient experiences. The drive to better wrangle data and processes drives education efforts to streamline documentation and compliance.

Enhanced document management and accurate coding, efficient, strategic reviews and VBR are improvements we can all get behind. And some of the keys behind a successful risk adjustment program that help deliver these improvements are skilled people, solid processes and the right tech.

SMART can help identify risk-adjustment conditions and automate your revenue cycle workflows. We work to understand their people, process and technology challenges and help recommend appropriate, innovative solutions.

Learn more and get in touch with our team.