Pre-Encounter Risk Adjustment: If You Try Sometimes, You Get What You Need

Emily-Bonham-Health-Fidelity-Healthcare-ITAs the significance of provider risk adjustment grows, especially within the clinical workflow, finding the right solutions and adopting them in the right order is a critical part of success. Today, I want to discuss that, as well as exploring an unorthodox approach: using pre-encounter risk adjustment strategies that also supports care without burdening physicians with additional non-clinical work.

With decades of healthcare IT development pushing more and more onto doctors and other providers, a new approach is as clear as it is necessary: the best place for most provider organizations to begin with a risk adjustment solution is with Post-Encounter Review. It has the smallest impact on physicians while supporting coding and risk accuracy, and often even funds the next step through its ROI. Starting with a post-encounter solution can also lead to a mutually beneficial relationship with payer organizations; it allows for Medicaid risk adjustment in states where a retrospective review by payers is not permissible.

After that, we almost always recommend expanding to a pre-encounter risk adjustment solution (rather than point-of-care) for many of the same reasons. Lumanent Pre-Encounter Prep uses clinical suspecting, a process through which Lumanent Insights, our NLP engine, surfaces conditions that are suspected, but aren’t formally diagnosed, for clinical review. Through adopting Pre-Encounter Prep, the goal of complete and accurate risk capture takes on a new shape: a tandem, two-step effort where a clinical review specialist identifies the highest probability missing conditions and then passes them to the physician for examination and any treatment during the encounter.

While it’s a risk workflow, in a sense, clinical suspecting is a high-tech, high-powered chart review that combs through every available piece of patient data to identify those undiagnosed conditions, or conditions requiring regular assessment per CMS. When conducted prior to an encounter, the practice can better support its high-risk patients.

Suspected conditions with a high degree of confidence (the thresholds of which are determined by the organization) are provided to the care team to validate prior to the visit. What happens next depends on the practice and the physicians. While the likelihood of those suspects is still high, the review of the suspected diagnoses (and their evidence) prior to the encounter doesn’t need to fall on the physician. We recommend establishing the role of clinical review specialist, coders with clinical knowledge or other care team members with clinical experience looking to expand their coding skillset. With the suspects vetted by the clinical review specialist in Lumanent Pre-Encounter, an additional expert human layer takes the administrative work off of the doctor’s plate, further allowing them to focus on care. Pre-Encounter Prep can pass approved suspects to the physician via the EHR or other tool at the Point-of-Care, or if EHR adoption is mixed, provide a list of conditions for analysis. In either case, the physician is armed with additional clinical focus, with minimal administrative burden in the encounter itself, to subsequently address and document the new conditions.

Pre-encounter risk adjustment even has an impact after the encounter, as well. Net new diagnoses from any care guided by Pre-Encounter Prep are already clinically validated to the standards of your team and the NLP engine. This, in turn, leaves greater coder resources to focus on any other suggestions made prior to submission.

This is what we mean whenever discuss re-centering risk adjustment around the patient. By wrapping the visit itself with NLP-enhanced guidance around risk adjustable conditions, but not intruding on a physician’s time with administrative work at the point of care, the care and revenue benefits are realized. There’s also an additional feedback loop: the quality of documentation rises, creating a more accurate patient records, which supports depth of care and the physician/patient relationship, and any health status changes are caught sooner. Finally, any relevant reimbursement is complete, accurate, and compliant.

This brings us back to where I began: the idea of provider risk adjustment is often incorrectly regarded as yet another burden laid at the feet of physicians. While accounting for risk can certainly impact care they provide (via insights), it is something that is a part of an organization’s approach to care and revenue, and incorporate the expertise and time of coders and the care team.

If you’d like to learn more adopting a pre-encounter workflow, our newest white paper is available here.