Risk adjustment tools are critical for healthcare plans, as they help estimate the cost of treating a patient in a given year, based on their specific health needs. This helps ensure that health plans are compensated appropriately – creating a weighted system for those who require more or more costly services. Additionally, this enables the providers to treat patients with different needs and not just healthier, less costly patients. Here are some of the top risk adjustment tools healthcare plans should have at the ready.

Coding Tools

Medical coding plays a key role in risk adjustment, as it creates a consistent and quantifiable measurement and categorization of the medical needs of a specific patient. A medical coder takes the physician’s notes, codes them appropriately, and enters them into a database or spreadsheet for record-keeping, compliance, reporting, and more. 

These codes are used to determine the risk adjustment score – also known as the risk adjustment factor (RAF) – of that patient. Coding helps create a more accurate record of a patient’s health, which in turn helps get more accurate risk adjustment scores. 

If your team is working out of a spreadsheet or an antiquated system that does not provide reporting or customization, this process is strenuous and can leave you open to compliance issues. Using a tool like our Episource Coder helps to reduce the manual labor involved and mitigates compliance issues.

Chart Reviews

Getting another set of eyes on your work for quality assurance is never a bad idea. That is why conducting regularly scheduled chart reviews and audits are important risk adjustment tools that can help catch and clean errors and discrepancies, improving the accuracy of your data.

Finding internal bandwidth to conduct these audits can be difficult for healthcare professionals, and having a knowledgeable team conduct these is paramount. This is why we provide Chart Audits – to validate proper coding, identify coding without supporting documentation, and ensure that claims are substantiated by clinical data from the medical record.

Risk Adjustment Compliance Tools and Services

Leveraging risk adjustment compliance tools and services is well worth the investment, as non-compliance can lead to substantial financial penalties, a hit to an organization’s reputation, and increased regulatory scrutiny from audits. Here are a few we offer to help avoid these outcomes:

Compliance Pack

Compliance Pack is a report that clients can continually generate from Episource Analyst, our risk adjustment analytics platform. This report pulls four diagnosis categories that pose compliance risk and outlines them in a report:

• High-risk HCCs identified by OIG
• Acute stroke HCCs without corresponding institutional claims
• Major depressive HCCs captured once in calendar year
• Diagnoses from HRA without a corresponding annual wellness visit with a primary care physician

Retrospective Compliance Cleanup

Our Retrospective Compliance Cleanup combines tools with service, as we analyze and flag areas that present a high-audit risk and pair you with an expert to help discuss next steps and cleanup strategies.

Analytics and Reporting

Capturing your medical coding accurately and having it readily available for auditing and compliance is important, but data alone can be overwhelming. This is where strong reporting and analytics tools come into play. Some important reporting features include:

Gap Analysis in Your Risk Adjustment Tools

A gap analysis pulled from your historic medical coding records can identify what treatments t are currently not being leveraged. This can then inform current and future campaign initiatives.

Chase Lists

Retro-Chase lists highlight any previously missed diagnosis codes that could impact risk adjustment scores and consequently reimbursement opportunities. Retro-chase lists refer to lists of patients whose medical records need to be reviewed retroactively to ensure all relevant diagnosis codes have been properly captured and documented.

SDOH Analysis

By capturing and assessing information regarding social determinants of health – including age, gender, zip code, race, and ethnicity, providers can identify groups that could benefit from additional care.

These reports and more can be generated using a tool such as Episource Analyst, a comprehensive risk adjustment analytics platform that turns data into actionable insights at the touch of a button.

Risk Adjustment Tools For Health Plans, Offered by Episource

For healthcare plans offering  Medicare or Medicaid services, risk adjustment tools play an integral part of your business. At Episource, we pride ourselves in a suite of connected tools that assist in some of the largest components of medical coding, compliance, and risk adjustments.
If you are interested in learning more about these tools, or the services we offer to supplement them, contact us today.