Accelerating Recovery in Reimbursement for Value-based Care Post COVID-19

Accelerating Recovery in Reimbursement for Value-based Care Post-COVID Author Robin LloydOn the heels of recent policy updates from CMS and the CDC, healthcare providers have quickly enabled telehealth and slowly begun to restore access to in-office visits. It will be many months before encounter volumes reach anything approaching pre-COVID levels, but the focus of providers and health plans has turned to ensuring care continuity and accurate risk capture for value-based care populations. This means adapting risk capture tools and practices to a profoundly different care environment and reimbursement process.

The rapid adoption of telehealth tools, for example, will require a period of learning and adjustment for providers and patients alike. Many clinicians were already struggling with the wide range of documentation and administrative tasks being presented during each encounter. As they navigate the telehealth learning curve, there is an increased likelihood of condition capture gaps and incomplete documentation. These gaps are particularly damaging today, with fee-for-service revenues having bottomed out and many provider organizations in a precarious financial position.

Implementing a “concurrent,” (also called pre-claim or post-encounter) coding review is an effective way to ensure complete and accurate capture of all 2020 risk adjustable conditions. This, in turn, can help protect value-based care reimbursement from erosion. Considering the pent-up need for chronic disease management, taking action now, before encounter volumes rebound more fully, is ideal for a few reasons:

  1. Most projects requiring substantial integration with or customization of EHRs have been placed on hold; a post-encounter workflow can generally be enabled with minimal EHR integration effort.

  2. It is early enough in 2020 that most members with chronic conditions will likely still have one or more encounters, maximizing the likelihood that all conditions can be diagnosed, documented, and treated in time for 2020 submission deadlines. Within that, the surge of returning encounter volumes, and therefore documentation of conditions that have gone untreated, can kickstart any care management initiatives, as well as a more thorough risk adjustment program.

  3. Coders are available during the post-ACA submission break for training (remotely, if needed) on post-encounter capture tools and best practices, ensuring that concurrent review productivity and accuracy peaks along with rebounding encounter volumes.

The benefits are not limited to the provider organizations, either. Payer organizations, particularly provider-sponsored plans, have a share stake in continuity of risk capture and stabilization of appropriate reimbursement for risk-based contracts. When payers support and even co-fund providers’ use of concurrent coding tools, both can realize the following benefits:

  • Faster claim processing and shorter revenue cycles. Coding is complete and accurate on the first submission, resulting in a timelier reimbursement and a measurable drop in accounts receivables (A/R) cycles.
  • Improvement in VBC benchmarks thanks to a more accurate reflection of population disease burden.
  • Alignment across documentation, care plans, and claims. Unlike most retrospective review processes, providers can be updated promptly about valid conditions requiring an update to clinical notes.
  • An ability to properly capture risk in Medicaid populations and others not reachable via retrospective risk adjustment.

Concurrent risk adjustment offers the ability to capture risk closer to the encounter without burdening clinical teams, while informing care and stabilizing revenue. Folding in concurrent coding to your risk adjustment repertoire is simpler than you think; the best approach utilizes natural language processing to identify gaps supported by clinical evidence for coder review as Lumanent Post-Encounter Review does.

Contact us today to learn more about how to bring your organization onboard. We are able to implement and provide web-based training to organizations who are working remotely.