As healthcare practices strive to deliver quality care while navigating the complex regulatory environment, managing financial risk becomes critical. Conducting internal risk adjustment audits is a crucial strategy for ensuring accurate financial reporting, compliance with healthcare regulations, and improving patient care outcomes.

Why Internal Risk Adjustment Audits Matter 

1. Ensuring Compliance: Healthcare practices are subject to rigorous regulations, especially concerning risk adjustment in value-based care models. Internal risk adjustment audits help identify inaccuracies in coding, documentation, and reporting that could lead to penalties or loss of reimbursements. By proactively auditing risk adjustment data, healthcare providers can ensure compliance with industry standards, reducing the likelihood of external audits or fines. 

2. Accurate Reimbursement: Risk adjustment is designed to balance payments to healthcare providers by accounting for the health status and demographics of patients. Internal risk adjustment audits ensure that coding accurately reflects the care provided, leading to correct reimbursement rates. They can prevent financial losses due to undercoding or overcoding, ultimately protecting the financial health of the practice. 

3. Improved Patient Outcomes: Accurate documentation of patient conditions ensures that healthcare providers offer appropriate care tailored to the individual’s health status. Internal risk adjustment audits highlight areas where documentation may need improvement, ensuring that patients receive the appropriate level of care and that care teams have a full picture of a patient’s health. This process directly contributes to improved care outcomes and patient satisfaction. 

How NLP Technology Can Enhance Internal Risk Adjustment Audits 

1. NLP-Enhanced Chart Audits: The sheer volume of data involved in internal risk adjustment audits can be overwhelming. Technology solutions, such as NLP-enhanced chart audit tools can streamline the audit process by automatically scanning patient charts, identifying discrepancies, and flagging potential issues. This reduces human error and accelerates the audit process. Episource’s Final Check Review service is an NLP-assisted chart audit that identifies missed codes and codes that fall into high risk category as per OIG’s guidelines. We review charts previously coded by other vendors to improve upon the quality and accuracy of coding results. We validate proper coding and identify coding without supporting documentation, ensure claims are substantiated by clinical data from the medical record, and make sure that newly identified codes are carefully reviewed and captured per guidelines.

2. NLP-Backed Compliance Packs: CMS, OIG, and the DOJ are cracking down on noncompliant risk-adjustment practices, increasing the amount of audits performed on health plans each year. Our Compliance Review tool combines internal research with documentation provided by CMS and OIG to analyze health plan data for HCCs that have a high likelihood of being selected for a regulatory audit. 

Our Retrospective Compliance Cleanup leverages analytical software to surface and resolve compliance risk present in historic submissions. It Isolates 10+ categories of high-risk codes and audits these for ICD-10 compliance to identify what can and cannot be validated with the available data and lays out a roadmap for remediating risk. Issue codes are confirmed or invalidated via NLP-powered 2LR. 

Conducting regular internal risk adjustment audits is a proactive strategy that benefits healthcare practices in multiple ways—from ensuring compliance and improving financial accuracy to enhancing patient care. Leveraging technology makes the audit process more efficient, accurate, and scalable, allowing healthcare practices to focus on what they do best: providing excellent care to their patients. By embracing modern technology and data-driven tools, healthcare practices can not only improve the audit process but also secure their financial future and deliver higher-quality patient care. 

Key Takeaways:

• Internal risk adjustment audits help healthcare practices ensure compliance, accuracy in reimbursements, and improved patient outcomes. 
• Technology solutions like NLP-enhanced chart audit tools and compliance packs can significantly enhance the efficiency and accuracy of internal audits. 
• Conducting regular audits using advanced technology helps healthcare practices stay ahead in a competitive, regulatory-driven environment.