As risk-sharing contracts continue to proliferate, providers must balance the reimbursement requirements of multiple payment models. This is especially true for programs like Medicaid, where reimbursements are harder to predict and manage. Operating within different value-based care and fee-for service approaches simultaneously creates financial and care management challenges, if care teams aren’t supported with the proper tools and resources to identify and address risk and quality gaps for all patient populations.
But the transition to value-based care doesn’t have to be complicated. The right infrastructure investment can provide a comprehensive view of health statuses and inform risk adjustment across multiple populations, payers, contracts, and EHR systems within a single workflow for a simple and universal process regardless of reimbursement model.
A New View for Value-Based Care
By augmenting the standard patient encounter lifecycle with EHR-integrated, workflow-based insights sourced from clinical documentation, the task of developing an accurate portrayal of the disease burden across varying patient populations becomes simpler and more balanced across the care team.
Armed with the analytics to identify and prioritize, the tools to engage and document, and the safeguards to support and manage those patients most in need of targeted interventions, risk adjustment and quality initiatives can be efficiently addressed to ensure better patient outcomes.
Our Modular Solution Suite Allows Providers to:
- Identify the patients that need to be seen
- Address and close care gaps
- Equip the physician with evidence to determine suggestion validity
- Ensure proper condition documentation
- Populate the claim
- Manage risk for multiple models, including Medicaid
How to Get There
Health Fidelity’s technology-enabled workflows facilitate complete and accurate risk capture:
Identify high-probability, suspected risk gaps from multiple patient populations
Simplify chart prep and utilize non-physician resources to increase confirmation rate before physician review
Deliver high-probability gaps to physicians through the EHR to be reviewed at the point-of-care
Facilitate proper documentation and closure of identified gaps
Identify and close gaps in documentation and coding before the bill is submitted
Leverage NLP to increase review productivity, accuracy, and efficiency
Pre-Encounter Prep Workflow
- 1NLP processes patient’s historical clinical data from EHR alongside claims history to identify suspected risk capture gaps
- 2Office staff conducts patient outreach and scheduling based on stratification of identified risk
- 3Clinical Review Specialist (CRS) inspects scheduled patients’ identified gaps in a prioritized work queue
- 4(Optional) A query to the physician can be generated for additional verification for pre-encounter chart prep
- 5(Optional) Verified conditions can be added to the problem list or pre-encounter chart documentation
- 1Identified gaps (that have been verified by the pre-encounter workflow) are pushed into the EHR; or
- 2NLP-identified gaps are directly pushed into the EHR
- 3Physician reviews outstanding gaps during the patient visit and “accepts” or “rejects” the identified gaps
- 4Accepted conditions are automatically added to the EHR’s problem list, visit diagnoses, and if chosen, to the physician documentation
Post-Encounter Review Workflow
- 1NLP processes encounter documentation and identifies documented diagnoses that have not been coded
- 2A prioritized coding queue is create based on gap closure opportunity identified
- 3Coder reviews NLP-identified coding opportunity for additions and deletions of diagnoses
- 4(Optional) A query to the physician can be generated for diagnoses that require further documentation
- 5Identified coding gaps are closed via addition or removal of diagnosis codes to/from claims
Provider Solutions Support Services
Supplement your transition to technology-enabled risk adjustment with our Support Services:
Consult with our industry experts for a customized review and comprehensive implementation plan that reveals where to focus your risk adjustment activities.
Ensure timelines, estimates, and expectations are accurate and regularly communicated to project stakeholders with a dedicated account manager during your deployment and throughout the duration of our partnership.
Augment your coding capacity with our highly trained and certified coding staff capable of performing first or second pass reviews using Lumanent Retrospective Review.