Health Data Vision Blog

View our latest posts

4 Key Obstacles to Operationalizing Concurrent Risk Adjustment Reviews

Posted by Bryan Lee on Tue, Jul 21, 2015

If you are reading this, chances are you agree with my previous blog’s premise that performing concurrent risk adjustment activities are increasingly important. Or perhaps you had already arrived at that conclusion previously.

Just wanting to do something is not enough, however. A concurrent review process is sufficiently different from a retrospective one to merit serious thought and planning. As we have been developing our platform and adapting our services, we have learned some valuable lessons. Here are some of the top obstacles and pitfalls to be considered when moving towards concurrent:

  1. Data Flow: Having the right data to start with is critical. Aside from good suspecting and provider data, plans should take a Verify-Delete-Add approach. This means good encounter data is needed and the MRR platform needs to be able to handle that data to be useful.
  2. Provider Abrasion: Providers are bombarded with increasing numbers of chart pull requests. Provider abrasion is ever increasing as all of your competitors get into or increase the scope of retrospective chart reviews, especially now that commercial exchange plans also risk adjust. With concurrent, the frequency of chart requests goes up. It is critical to have an approach that does not further tax the already thin patience of providers.
  3. Taking Action: Aside from getting a clear picture of revenue and other aspects derived from medical records, a key aspects of concurrent review is gap closure. Tight review cycles afford plans the time to perform meaningful campaigns to close identified gaps.  Make sure you have a plan and the tools to act on the information to close as many gaps as possible.
  4. Cost: It stands to reason that more chart review cycles will cost proportionately more money. Money that may not be in the budget. What can you do? Tackle the two main cost factors in the MRR process: Retrieval and Coding. A lot of it can be done with technology, to the point that the providers are actually less bothered than before. And a new approach to coding based on the encounter, not the chart. The numbers are surprisingly different.

Whether you are using our platform, another vendor’s or your own workflow, these issues will be constants and deserve all our attention as we expect to adopt concurrent reviews more and more.

Tags: SaaS, medical record review, risk adjustment, MRRV, provider data, provider relations, revenue optimization, MRR, revenue management, big data, provider abrasion, workflow, Coding, Concurrent, verify, verify-delete, retrospective chart review, gap closure, encounter, delete, retrospective, data flow

Why Concurrent Risk Adjustment Reviews Are Becoming an Imperative

Posted by Bryan Lee on Mon, Jul 13, 2015

Pretty much anyone within the Risk Adjustment world talk about similar topics of concern: the need to accurately capture and protect revenue, proactively assess and manage member health, contain cost, and improve quality. All while the regulatory landscape becomes more demanding and risk adjustment becomes more commonplace and varied. For example, submission of corrected claims are gaining greater scrutiny by regulators, as a means to identify fraudulent billing practices.

Historically, retrospective chart reviews were most commonly deployed for influencing risk scores and improving revenue. This look-back into a member’s medical record has often been 12 to 18 months beyond the encounter date. The delay in correcting the submission of data to a plan’s regulators contributes to a wide variability in risk scores and ultimately in reimbursement.

Regardless of which concern one focuses on, the need to submit COMPLETE and ACCURATE data in a TIMELY fashion is the recurring theme. Plans are compelled to remedy data (and document) lags. The sensible solution, then, is to continuously review medical records as medical encounter data becomes available.

This process essentially boils down to continual reviews focusing on recent encounters as driven by the encounter data (which is about as ‘concurrent’ as it gets). The triggering event for a concurrent RA review is driven by a claim submitted from a provider so abstraction of the medical record can be timely. In turn, this enables a host of follow-on activities, member outreach, provider education, and, more accurate and complete submissions to regulators through further integration with the plans EDPS processes.

So concurrent RA reviews enable a plan to better balance the information requirements of the regulators and to establish greater controls on revenue generating activities and the many related activities.

Implementing a concurrent review process can be tricky and costly. Read about some key considerations in our next blog.

Tags: quality improvement, quality measures, medical record review, risk adjustment, provider data, healthcare data, healthcare data analytics, revenue optimization, medical record analysis, revenue management, Concurrent, reimbursment, encounter, EDPS

HEDIS® Season - Why Being "On" in the Off-Season is So Critical

Posted by Michael Curran on Mon, Jun 29, 2015

             As another HEDIS season comes to an end, most of us are carrying reminders that no matter how you approach the business of chart retrieval and abstraction, it seems to remain hard work with numerous dependencies for most health plans.

             It’s typically at this time of year that I’m reminded of the guidance from W. Edwards Deming (one of the heads on my personal Mt. Rushmore of Quality Management) concerning supplier relationships. Deming’s philosophy of Total Quality Management and continuous improvement had been aggressively adopted by my then employer and having the good fortune of working at an organization with close ties to Harvard University, I had the privilege of attending a lecture given by Deming in 1990. Even at 90 years old he maintained an authoritative presence and spoke with a conviction and the passion of a recent convert.

            The key message I took away from that hour with Deming was how much quality depended on the quality of relationships both those internal to a company, embodied in his message of “driving out fear” within an organization, as well as outward facing, embodied in his message about the value of investing in long term relationships with suppliers or vendor partners, as I like to think of our organization. Vendor partners that understand the needs today, have a vision for the future, can execute and have the competence and passion to work with their plan partners year-round.

             I believe those two notions are exceedingly important in developing strategies to continuously improve the quality and completeness of hybrid reporting for HEDIS. A “one and done” approach to working with Medical Record Review or NCQA Certified HEDIS Software vendor partners will rarely address the issues related to reporting the most accurate HEDIS rates.

             As a standard practice at HDVI, we advocate for and build year-round relationships with our plan partners and recognize that HEDIS hybrid rates are improved more from the work done by the plan-vendor partner teams between June and January (often called the off-season) than what is done between January and June will go a long way toward improving rates across the board for hybrid measures while often saving a lot of stress, aggravation and even money.


Tags: quality improvement, NCQA, HEDIS hybrid, HEDIS, MRR, off season, vendor

PMH - To Code, or Not to Code?

Posted by Donna Kober on Mon, Jun 08, 2015

ICD_10_tri_colorI was writing an article for the AAPC Edge and I wanted to make sure I had my facts correct about the importance of the diagnoses in the PMH section of the documentation. So I called my sister in law who is an Emergency Room Trauma physician. I posed this question to her: Do doctors (providers) use medical history (PMH) diagnoses in their decision making when assessing a patient?

She responded that physicians review the PMH to form a foundation of the patient’s medical issues. Then after the examination they can use the PMH to assist with differential diagnoses or to assist in the determination of treatment for that specific encounter.

So, if the chronic and past conditions are used by physicians in the decision making process, wouldn’t that be considered as part of the evaluation of a patient therefore fulfilling the “E” in the MEAT validation concept? I know some coding experts say, “if it isn’t written, it wasn’t done.” At the same time, I can’t see any provider actually writing “I took into consideration the PMH diagnoses in my decision making”. Coding all chronic diagnoses from the PMH provides insurance companies and CMS with a holistic picture of the patient on that specific date of service.  

I am not saying coders should be coding all the diagnoses in the PMH as current diagnoses, if they are a “history of” they should be coded and categorized as such, but the chronic conditions that never go away will always have an impact on the decision making of providers, so why not code them?

Tags: CMS, ICD-10, healthcare coders, Coding, HCC, MEAT, PMH

It's Prime Time for the MRR Workflow Platform

Posted by Michael Klotz on Tue, May 26, 2015

When we set out to create a workflow platform for everything Medical Records Review a few years ago, we had a very good idea of what it should be and do, what its benefits would be and how it would address a number of pain points payers (and providers) have with the MRR process. A vision, if you will.

As another HEDIS season is coming to a close and we see, for example, how the preparation and response to the MRRV, the dreaded audit of the MRR portion of the annual quality review, has changed (among other things), I can’t help but be a little proud. Chaos, disorder and countless hours of pulling records together have been replaced with putting a checkbox next to a few member names and clicking a ‘Generate Audit Package’ button, in this case.

Certainly, the enterprise workflow platform we have created is not exactly what we had in mind at the time. We got a number of things right, we made mistakes (and fixed them), we heard from our customers what they really needed and addressed those needs and continue to do so. What we know with a good amount of certainty today what the key aspects of such a workflow platform are:

  1. Configurable and Flexible – we have realized how important it is to allow our customers to staff and run their projects the way they want to
  2. Comprehensive – the status quo was that health plans had to cobble together a number of people, vendors and technologies to get meaningful results. It felt more like herding cats than managing at times. We took the approach of creating a platform that addresses all MRR needs, from Risk Adjustment for all lines of business to HEDIS to one-off audits, the ability to get every medical record, with built-in functionality supporting everything from provider data verification to built-in RADV readiness
  3. Real-Time Visibility – as we look at real-time dashboards of every aspect of the MRR process, it’s hard to imagine how we ever managed without. The term ‘flying blind’ comes to mind when we think about how little timely information was available in the past.
  4. Provider-Friendly – to our surprise, a little feature called Secure Virtual Print, is a big hit. In retrospect, it’s not surprising since provider abrasion is one of the top concerns and Secure Virtual Print really helps on that front. A lot.
  5. Part of the Big Picture – as important as risk adjustment and HEDIS Hybrid projects are, they are part of a larger, usually member-centric, care cycle. To continuously add value we are making our platform a seamless part care management, provider education and gap closure processes. For example, a care manager can pull up the ‘Member Timeline’ dashboard, which visually shows all review periods where a medical record is available, with encounter dates and many additional data points and the ability to click through to the relevant pages on the record in a matter of seconds.
  6. Reliability, Scalability, Speed & Security – obvious ones, but without these, nothing else really matters

As we continue forward implementing some of those ideas we haven’t gotten to and the many we have come up with since, we will follow these guiding principles. They have served us and our customers well so far.

Tags: health plan providers, SaaS, chart review, medical record review, risk adjustment, MRRV, HEDIS, MRR, workflow, secure virtual print

HEDIS® 2015: Identify Data Gaps Now and Take Action To Close Them

Posted by Michael Curran on Mon, Jun 23, 2014

With HEDIS® 2014 completed, now is the time to start planning for HEDIS® 2015. While the active medical record collection period is short, HEDIS® is a year round activity. There are many opportunities that can be acted on now to make next results even better for many it’s a matter of data gaps and identifying where those gaps exist and taking action to close them can drastically improve your HEDIS® and STARs rates next year.


Reviewing HEDIS® 2014 results with claims data throughout the year can give you an insight into where data gaps with quality of care measures that impact HEDIS® and STARs results. When analyzing this information, you can identify interventions for your health plans, providers and members. It is important to prioritize interventions by the impact they can yield.
For health plans, consider what is driving your gaps.
  • Are gaps resulting from network leakage due to members visiting providers that are not participating with the plan and aren’t obligated to provide medical record information? If so, work with your benefits department to identify ways to message members about in-network benefits.
  • Are there large provider groups that are resistant to cooperating? 
  • Do they have EMR? What incentives can you provide to encourage participation?

Engage provider network management to find ways to work with challenging provider groups now to make HEDIS® 2015 smoother. Are there other supplemental data sources that can help improve rates.  For example, investigate state registries for immunizations.

STARs data

Provider engagement is another key way to improve HEDIS® 2015 and Stars results. Providers are challenged with day-to-day operations of their offices and may not have the resources available to identify members needing preventative screenings or chronic care management. Targeted reports providing them with up-to-date patient information can assist them in their outreach efforts to encourage members to receive timely care. In addition, identify ways to offer providers options for HEDIS® 2015 that can reduce provider intrusion. Do they have EMR that can be accessed remotely? Do they want to schedule early so they can anticipate and schedule your HEDIS requests with other plans? Sometimes it’s the little things that make the provider’s life easier that can help with getting the responsiveness you need for your HEDIS® data collection.

The health care system is challenging to navigate. By making it easier to understand, members can become more engaged in managing their health. Depending on your membership demographics some outreach efforts are more effective than others. Consider a multi-prong approach such as mailings, voicemail and health educator outreach to members based on preventative screenings and chronic care management. Optimize care management programs to remind and follow-up with members needing services. Sometimes members need a call to action and some guidance – it’s a win-win. Members get the care they need and you get the needed information to help them maintain or improve their health.

By focusing now internally and collaborating with providers and members, you can design interventions to impact the data in time for HEDIS® 2015 and close the gaps that exist.

By Elizabeth Micholovich, Senior Project Director, Health Data Vision, Inc.

Tags: HEDIS audit, HEDIS measures, STAR rating, HEDIS, healthcare data analytics, HEDIS results, NCQA HEDIS

HDVI Comments on the CMS Final Rule for 2015 Medicare Advantage and Prescription Drug Benefit Programs

Posted by Jen Wallace on Tue, Jun 10, 2014

The new rule published on May 19, 2014, revises the Medicare Advantage (MA) and Part D prescription drug benefit programs regulations to implement statutory requirements, improve program efficiencies, clarify program requirements, and improve payment accuracy for Contract Year (CY) 2015 in general. The provisions in the rule are effective immediately.

The final rule is accessible here.

Health Data Vision has analyzed these new rules and how they affect Risk Adjustment processes for Medicare Advantage plans. This blog summarizes and comments on the most significant points of these rules.

Problem: Tightened timeframes

Improving payment accuracy: The final regulation would implement the Affordable Care Act requirement that MA plans and Part D sponsors report and return identified Medicare overpayments.  After the final risk adjustment deadline for a payment year, MA organizations will be allowed to submit data to correct overpayments but cannot submit diagnosis codes for additional payment.  The provision codifies and clarifies rules regarding when Part D and MA plan sponsors must report and return overpayments. 

This requirement effectively tightens the timeframe in which Plans will be incentivized to verify the diagnosis that have been submitted through claims. Once outside that window, plans will be required to return over-payments without the ability to submit corrected diagnosis codes. Thus leaving only a downside for the health plans. For this reason Verify or Delete will become a much more sought after mechanism during chart reviews, particularly ahead of January sweeps.

HDVI’s addresses these tightened timeframes with the Verify, Delete plus Add functionality in our Workflow Platform.

Problem: More RADV’s More Often

Improved MA risk-adjustment data validation (RADV) audit appeals procedures: The rule strengthens RADV by streamlining the RADV audit appeals process by combining error rate calculation appeals and medical record review-determination appeals into one combined process.  The streamlined process will reduce administrative burden on both MA plans and CMS.

CMS is making efforts to streamline the entire RADV process.  The working assumption is that it will create a system where more plans can be audited on a regular basis.  If this assumption is correct HDVI will see more demand for RADV assistance.

HDVI already has a strong automation service for RADV that reduces the effort and time required for RADV responses, while eliminating the majority of uncertainty and negative financial impact. Learn more about HDVI's Mock RADV.

Problem: Critical Reporting Measures

Expanded prevention and health improvement incentives: The final rule expands rewards and incentive programs that focus on encouraging participation in activities that promote improved health, efficient use of health care resources and prevent injuries and illness. 

CMS has now incorporated the requirement to improve health for Medicare Advantage members.  This means that reporting results of chart audits will become critical information to filter back to the plan for improvement initiatives. The reporting results will need to be audit specific, DOS specific and provider specific, which will require much more work than before. Computer assisted coding, error resolution and extremely efficient record retrieval are necessary in order for health plan’s to facilitate the increased volume before the reconciliation deadline.

With HDVI's Real-time Analytics and Secure Virtual Print Technology, increased volumes of health plan reporting are handled with ease, while (SVP) reduces provider abrasion.

Problem: Identifying Revoked Providers

Permit revocation of Medicare enrollment for abusive prescribing practices and patterns: CMS is adding the authority to revoke a physician’s or eligible professional’s Medicare enrollment if:

  • CMS determines that he or she has a pattern or practice of prescribing Part D drugs that is abusive, represents a threat to the health and safety of Medicare beneficiaries, or the pattern or practice of prescribing otherwise fails to meet Medicare requirements; or

  • His or her Drug Enforcement Administration (DEA) Certificate of Registration is suspended or revoked; or

  • The applicable licensing or administrative body for any state in which a physician or eligible professional practices has suspended or revoked the physician or eligible professional’s ability to prescribe drugs. 

Providing CMS the authority to revoke such prescribers’ Medicare enrollment will help protect beneficiaries and the Medicare Trust Fund from fraud, waste and abuse.

It is not clear how CMS intends to track or communicate these revoked physicians, likely through the NPI/Taxonomy database. NPI is now a required submission element, so it is possible that CMS will simply reject certain NPI’s. This should be monitored closely in order to learn more and how to avoid submitting diagnoses from providers that are no longer permissible to treat Medicare Members.

A National Provider Database is frequently updated and available in HDVI’s Workflow Platform.

By Kristen Joyce, HDVI - Senior Director, Risk Adjustment

Tags: medical record review, MRRV audit, CMS, Prescription Drug Benefits, risk adjustment, medicare risk adjustment, medicare risk

Risk Adjustment for Health Exchange: Why Plans Are Prepping

Posted by Michael Curran on Thu, May 22, 2014

Exchange participation is creating new challenges as more health plans enter health insurance exchanges and realize a solid Risk Adjustment model must be planned, built, and set sail before a tidal wave of transfer payments hits their deck.  Imminent threat of revenue loss due to poor data collection processes may sink otherwise thriving plans as they watch their money being swept back to sea by the rip current known as ‘reallocation of premium’ or risk adjustment transfers.  Further loss of future revenue looms large as plans with poor risk models skip the opportunity to shore things up with quick and proactive provider education. And the oncoming tidal wave of CMS measures are challenging for even the industry experts.  To stay afloat, commercial plans must change course from a ‘selecting and protecting’ to an ‘absorbing and distributing’ risk model. 

Do Medicare Advantage Risk Models Translate?

Medicare Advantage plans have been navigating these waters for some time now, but experts agree, retrofitting a commercial plan with a MA Risk Adjustment model isn’t smooth sailing.  For one thing, data audit timelines are different and tightly compressed for risk adjustment activities and reporting in the exchanges. The timing is much shortened from data-submission to payment adjustments.  Another thing exchange plans will have to contend with is a smaller percentage of suspects, which at initial glance seems to lighten the administrative load, but in actuality, can be brutal to the results of even slightly inefficient plans.  To provide some insight into the financial impacts of your plan’s risk adjustment activities, the Congressional Budget Office estimated that we could be seeing $10 BILLION PER YEAR in risk adjustment transfers.  

Data & Revenue: Choice of Workflow Platform Critical

Health plans will be paid with levels of member health status taken into account, as reported by the health plan through their data collection activities.  This plan revenue, as explained in HHS regulations, will take into account member ages, genders, and documented diagnoses.  Since this information is privacy protected, the data and plan payment scores will remain housed within each individual health plan’s technology platform.  Of course, HHS regulations include auditing of this data, not once but twice by both your health plan auditors, while HHS determines your audit sample, and then again by HHS auditors.  Therefore, the workflow platform chosen by the health plan is critical to maximizing the efficiency of data management and revenue optimization. 

Since at this point, no one knows exactly what the audit data points will consist of, it makes choosing and building the most transparent and controllable data platform a must for health plans.  Transparency of the process, scalability and control will all play into the health plan success or failure to correctly extract quality audit data.  Financial and compliance implications, and significant operational workload will certainly beach health plans who drag their heels and are slow to launch.  Health plans options to design, test and implement risk models necessary to participate in exchange business include the option to purchase a scalable software platform.


Tags: CMS, risk adjustment, medicare risk adjustment, HIE, health plans, healthcare analytics, Medicare Advantage, Michael Curran, healthcare data analytics, healthcare data analysis, risk revenue, revenue optimization, health exchange, HIX, software platform, healthcare reform, medical records retrieval, medical records analytics

Enhance Quality of Care with the Financial Alignment Initiative

Posted by Dawn Zito on Mon, Apr 28, 2014

What is the Financial Alignment Initiative?

As a part of the Affordable Care Act, two new offices were created within Centers for Medicare and Medicaid Services (CMS) to test new payment and service delivery models that fully integrate care for dual eligible beneficiaries.  Dual eligible beneficiaries receive both Medicare and Medicaid benefits. These beneficiaries typically include low-income seniors and younger people with disabilities and have complex and often costly health care needs. 

These newly created offices, the Medicare-Medicaid Coordination Office and the Center for Medicare and Medicaid Innovation Center, partnered to create the Financial Alignment Initiative (otherwise referred to as the “Dual Demonstration”). This an opportunity for states to test models with two possible approaches (Capitated or Managed Fee-for Service) to align financing between Medicare and Medicaid while sustaining or enhancing the quality of care provided to Medicare and Medicaid enrollees.  The benefits under both models include primary, acute, pharmacy, behavioral health and long-term services and supports currently covered by Medicare and Medicaid.  In addition, plans can offer additional supplemental benefits not covered by Medicare or Medicaid.


Capitated and Managed Fee-for Service (MFFS) Models

The capitated model utilizes a prospective payment methodology where the health plan will receive a blended payment to provide care for the enrollees.  A three-way contract between the State, CMS, and the health plan is established.  CMS and the State will jointly select and monitor participating health plans. In this model, the anticipated savings are shared between CMS and the state. States approved for the capitated model to date are the following: California, Illinois, Massachusetts, New York, Ohio, South Carolina, Virginia, and Washington.

Under the MFFS model, the state is responsible for the beneficiaries care coordination and the providers will be reimbursed on a fee-for-service basis (by CMS for Medicare services and by the state for Medicaid services). MFFS utilizes a pay for performance methodology where the State benefits from the savings initiatives implemented to improve the quality of care and reduction in costs. The State would receive a retrospective performance payment for meeting specific quality metrics, demonstrating statistically significant savings in Medicare, and an overall reduction in Federal spending on Medicare-Medicaid enrollees. States approved for the MFFS model to date are the following: Colorado and Washington.


Process to become an Medicare-Medicaid Plan (MMP) under the Capitated Model

To participate in the Dual Demonstration, a State submits a letter of intent to CMS.  These proposals vary in such categories as eligibility, covered geography, enrollment mechanisms, implementation dates and phase-in plans, benefit packages, beneficiary protections, stakeholder engagement, quality measures and oversight.  There is a lot of variation as each state incorporate existing programs and state specific factors into their proposal.  CMS will then work to establish guidelines that outline the overall expectations in a Memorandum of Understanding (MOU).  A Medicare-Medicaid Plan (MMP) is a health plan that has applied through the State and CMS application process to participate in the Demonstration and has been approved via a joint process. The next step is for the State, CMS and the selected MMPs to enter into a three-way contract which provides guidance to the plans in order to implement the new programs.

By Shana Carrico and Alison Garton of Carrico & Garton Group

CGG provides clients with holistic solutions to operationalize new opportunities and optimize existing ones. CGG works with clients to solve complex operational or systemic challenges to ensure compliance, optimal performance and enhanced revenue.

Tags: health plans, medicare advantage plans, medicaid, dual eligible, affordable care act, financial alignment initiative, quality of care

Don't Delay on ICD-10 Training

Posted by Jen Wallace on Tue, Apr 15, 2014

icd10 7

The delay of ICD-10 is an opportunity for coders to improve their knowledge of ICD-10 as well as share this knowledge and insight with physicians. Health Data Vision encourages health plans, along with their coding/audit managers, to work together to offer ICD-10 training materials to their internal staff. This will keep everyone concerned knowledgeable and ready for the 2015 implementation date.   

A considerable amount of time, effort and money has been spent preparing for ICD-10 preparing for the Oct 1, 2014 implementation date, without extensions or exceptions. Now the implementation date has been extended until at least Oct 1, 2015. We believe that just like any other skill, if you don’t use it you lose it. With the delay in the implementation, for at least another year, coder’s should make efforts to remain proficient. In order to do so, coders must practice. We suggest that health plans, physician offices and coders take advantage of all ICD-10 training resources being offered by industry leaders such as AAPC and AHIMA.

Physician Education
This is the perfect time and opportunity to express the importance of detailed and necessary diagnostic documentation with physicians. ICD-10’s specificity of the reporting comes as a significantly expanded code set, 69,000 compared to 14,000 in ICD-9, and a higher responsibility to be clear in documentation. Coding managers and health plans need to take this additional time to provide physician education on proper documentation necessary for ICD-10.   

Better Documentation
Please keep in mind that this should not only be left up to the health plan, coders should also step forward and help their physicians’ by offering advice on how to better document their patient visits. The choices will be much more specific and require more detail in the medical record when assigning the appropriate code for the patient’s condition. Training physicians to know their choices now will make the ICD-10 transition easier for all parties involved. 

As we all know, change is not easy, but how we react to the change determines how successful we are. Regardless of how we feel about the delay of ICD-10, what we must do is embrace the change, keep preparing ourselves as coders and educate our physicians.

Tags: provider data, ICD-10, Delayed ICD-10, healthcare coders, health plans

Subscribe by Email

Posts by Category