The Coronavirus Pandemic introduces three unforeseen challenges to Health Plan Risk Adjustment Operations

The Coronavirus Pandemic introduces three unforeseen challenges to Health Plan Risk Adjustment Operations.

The American healthcare industry will undergo significant disruptions as the coronavirus crisis penetrates the American landscape. Three critical events are already affecting the Risk Adjustment operations process at America’s health plans for 2020.  First, a core requirement for health plans is the retrieval of patient charts throughout the year.  As the healthcare industry shifts quickly to “essential medical services” to open up capacity for COVID-19 patients, access to patient charts by non-essential personnel has largely halted. 

Secondly, patient office visits and hospital and ER visits have dramatically dropped as many States adopt shelter-in-place orders and require hospitals to serve only “life and death” and expected high COVID-19 patient volumes. Hospital and outpatient surgeries have dropped over  80% in many regions, and hospital ER and inpatient volumes have dropped in half in anticipation of the coronavirus impact.  This inevitably pushes out annual wellness visits and chronic care visits to bunch up later in the year if these visits are to happen at all.  

Third, shelter-in-place orders require health plan in-house coders and management to shift to a remote or “virtual” workforce environment.  Manual processes now become hard to replicate as security and privacy issues have to be assured, and workflow management systems have to be effective. Consequently, health plans are being forced to rethink their Risk Adjustment processes and implement innovative solutions. 

New Realities with Chart Retrieval

In order for health plans to have access to the physical copies of patient charts, they must visit the offices of medical providers and retrieve the charts. The threat of this coronavirus pandemic makes chart retrieval extremely limited or altogether impossible. 

Some health plans are already using e-retrieval methods to access the electronic medical records of the people it insures, but this method only permits online access to the records one at a time. Health plans typically are not able to download the EMR record, and many health plans and providers have yet to adopt e-retrieval systems. Therefore, they are not equipped to handle electronic patient charts. 

Chart retrieval is not expected to be an issue for long, though. Whether medical providers enable e-retrieval of patient charts or the pandemic subsides enough for proper chart retrieval, health plans can expect a medical chart tsunami in the near future. The inevitable surge of charts will lead to an immediate influx of work at one time. Health plans must be prepared to meet the demand with efficiency while maintaining coding accuracy. If they lack the necessary tools to quickly process charts, the heavy demand could lead to a decrease in coding productivity and accurate claims submission.  

Delay in Patient Office and Hospital Visits and Growing Chart Complexity

Even as the amount of accessible patient charts decreases, the amount of office and hospital visits will increase dramatically once the pandemic is brought under control. This is being partly addressed by the relaxing of billing standards for “telehealth medicine.”  And we are seeing a dramatic increase in such doctor to patient calls. If documented correctly, such telehealth calls can serve the Risk Adjustment coding process.  How this documentation enters the coding process needs careful scrutiny to be permissible.  

Adding fuel to the fire is that the increase of coronavirus cases is expected to inflate the amount of medical visits downstream for patients with multiple comorbid conditions. This will increase the chart complexity, adding to the work coders will have when a flood of patient charts is made available for processing.

Navigating a Newly Remote Workforce

While health plans are figuring out how to handle an increase of hospital visits and a logjam of patient charts, they are also being forced to make the switch to a remote workforce. Global shelter-in-place policies are requiring health plans to take their coders out of the office and transition them to a “virtual” work-from-home set-up.

Many health plans are not equipped for the transition, particularly if their coding work is outsourced to offshore coding vendors who themselves are facing challenges in the shift to work from home. The available workforce is expected to diminish while health plans are expected to maintain a high level of productivity. Health plans that are not prepared to enable remote workers could see a drop in productivity and coding quality. 

Together, these challenges are expected to negatively affect the quality and accuracy of chart reviews and coding. Health plans might not be able to meet deadlines, and the end result could impact their reimbursements.

Setting Health Plans up for Risk Adjustment Success in These New Times

As health plans prepare to continue their Risk Adjustment processes, there are steps they can take to maintain a high level of productivity and quality.

They can:

Enable remote or “virtual” medical coding

In order to do this, health plans need a system that is capable of combining in-house and remote coding into a hybrid model. The platform should be HITRUST-certified to ensure the security of sensitive patient data. 

Adopt software that can pull charts electronically

Some platforms can automate the pull of encounter data from EMR repositories, which allows proper chart retrieval when physical charts are not available.

Streamline workflow processes and encourage collaboration initiatives across teams

As charts move through the review process, there needs to be a clear process in place to ensure coding accuracy is upheld.

Partner with a technology vendor with reporting capabilities and visibility

In light of the remote workforce, health plans need to be able to check in on the individual activity and productivity of every coder. That includes seeing how long it takes to complete a chart. Transparency will help ensure coding accuracy.

Use a platform with sufficient bandwidth

Software needs to keep up with the magnitude of charts being processed at one time. Health plans are processing thousands of patient charts every day from multiple EMRs.

Consider software with machine learning capabilities

A software that can suggest codes and edits will boost the accuracy of Risk Adjustment scores and reduce the workload for coders. 

Ultimately, health plans need a “virtual” team in place that is efficient, capable, and flexible, anywhere, and anytime. In order to succeed, that team needs the proper tools to continue to deliver quality work and keep the Risk Adjustment process moving along. 

Talix is a leader in Risk Adjustment software. It has the most robust and flexible NLP coding platform on the market, and its interoperability with other applications makes it easy to integrate Talix with your current systems.