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Looking Ahead: The Impacts of COVID-19 on Risk Adjustment and Quality

The COVID-19 pandemic has generated a tsunami that has washed over every industry on the planet, and those of us who work in the business of risk adjustment (RA) are not immune from its effects. Surviving this pandemic means toughing it out, but truly thriving through it is all about finding opportunities and re-imagining how we operate while we are living in a bleak new environment for doing so.

When examined through a Medicare Advantage lens, the pandemic clearly reveals a series of near-, medium- and long-term effects on the business of risk adjustment and the professionals working in this novel RA landscape—as well as new opportunities. For the RA sector, the resulting “new normal” raises four overriding questions that must be considered if Medicare Advantage plans are to succeed in this unprecedented setting:

  1. What do we do now? What challenges and potential opportunities is COVID-19 already bringing to the RA business? How do we keep our people and organizations healthy and safe, while complying with all state and local guidelines for continuing to operate? What is the role of telehealth and what opportunities exist for operational efficiencies, education and critical activities in pursuing maximum return, to include building more electronic retrieval capacity and EMR integration?
  2. How do we navigate “pseudo normalcy” and what does that look like in risk adjustment? Eventually, pressure will ease on healthcare systems, and member outreach and support will need to begin to ramp up. It may even ramp up and then must stop a few times. How can we facilitate this contact with enhanced telehealth and online options? More information will need to be integrated into provider EMRs to strengthen these relationships. Also, the pandemic has the potential to greatly worsen the impact of social determinants of health (SDoH) as more people experience social isolation, loneliness, food insecurity and housing instability. SDoH may need to be considered more broadly in medical management.
  3. What happens when the team is back to work? Lockdowns eventually will end, and all the pieces of the healthcare system will fall back into place, but likely not into the same space as they were before. And again, there could be stops and starts that cause disruption and uncertainty far into 2021. Both Medicare Advantage and Physicians and other Provider Organizations will need to plan for this new structure well in advance so that they are prepared to launch with all elements of people, process, and technology ready to go. People with chronic disease will likely be much sicker after months of being told they can’t see their caregiver and not being properly monitored for their conditions. Care gaps that had been previously identified will remain unaddressed, so EMRs will need to be enhanced to facilitate better tracking. We must address the elements of ramping up, including retrieving as many records as possible that might require in-person scanning in case “ramping down” again becomes necessary.
  4. How do we make sure we are ready for 2020 year-end? From what we have seen so far, the only thing certain about COVID-19 is uncertainty. Medicare Advantage Organizations, and other Government Programs and their providers alike, need to plan for today’s reality to become tomorrow’s normal, so we need to adjust our mix of tactics. Procrastination on reporting is no longer an option. Health plan-physician (provider) partnerships will be more important than ever in easing the burden of regulatory reporting requirements, improving care quality, and reducing costs, and this will be an opportunity to strengthen them. This also will be the time to advocate with CMS to not only ensure that greater acceptance of telehealth becomes permanent, but also to encourage other approaches and models, including automatic revalidation of long-term conditions that do not go away.

Adapting in the near-term

By now, most organizations working in Risk Adjustment have become accustomed to the physical aspects of working in the new “stay-at-home” environment. We have set up our offices at home and have worked out the kinks in Zoom or Skype or whatever modality we are using to communicate with our staff and providers.

Now we are much more technologically adept (in theory), collaborating and sharing information almost exclusively by electronic means. Unfortunately, if you are like most people in this business, that was not what you were doing before the pandemic restrictions forced you to. Pre-COVID, most of the information you had collected for retrospective review was on paper, and if you were behind in that process at the time, you now are facing more challenges than those who were more reasonably ahead of the game.

Many in RA have been harping for years on the need for electronic medical record connectivity and interoperability, and I consider myself to be one of the loudest in that choir. I was always my hope that there would be a few among us that would champion this evolution – clearing the way for the rest – rather than an unprecedented crisis forcing adaptation and action.

As it has always been in nature, those who adapt are those who survive and thrive, so continue with your retrospective record collection and review process, with the limitations that have been placed on you by not being able to meet with your contacts on site. But also focus on developing greater capacity in electronic retrieval methods with vendors and establishing EMR connectivity where you can—innovate. If you don’t have the resources internally, find a partner or vendor to help you.

One improvement goal to consider during this period is developing incremental financial incentives for establishing electronic connectivity. Such connectivity will help future-proof operations if and when another wave of coronavirus strikes or if the current wave persists. Any planning you do at this point must take into account the possibility that we could be back in lockdown soon after things start opening up again. Connectivity is just one opportunity that the pandemic has created and accelerated. Telehealth is another, and its time may be finally here.

Telehealth gets a shot in the arm

On April 10, the Centers for Medicaid and Medicare Services (CMS) sent a letter to all Medicare Advantage, Cost, PACE and Demonstration Organizations that has been a long time in coming. Titled, “Applicability of diagnoses from telehealth services for risk adjustment,” the letter was a revolutionary statement for the RA world: “The 2019 Coronavirus Disease (COVID-19) pandemic has resulted in an urgency to expand the use of virtual care to reduce the risk of spreading the virus; CMS is stating that Medicare Advantage (MA) organizations and other organizations that submit diagnoses for risk adjusted payment are able to submit diagnoses for risk adjustment that are from telehealth visits when those visits meet all criteria for risk adjustment eligibility, which include being from an allowable inpatient, outpatient or professional service, and from a face-to-face encounter.”

The letter provides the following details for coders, solidifying this new opportunity: “In order to report services to the EDS that have been provided through telehealth, use place of service code ‘02’ for telehealth or use the CPT telehealth modifier ‘95’ with any place of service.”

Based on this guidance for use in risk adjustment, we need to keep up our vigorous support and advocacy for the use of telehealth through in-home assessments or provider office leads. Urge provider offices that might not have previously established a capability to consider identifying a telehealth capability vendor that can be made available for their offices. Develop provider education on telehealth coding and documentation requirements. Consider modifying provider incentives to encourage the use of telehealth in assessing and managing patients.

Other ways to support provider networks in using telehealth include:

  • Providing education about requirements of telehealth visits
  • Providing sourcing options for those providers, typically smaller, that do not have telehealth capability
  • Introducing temporary reliefs or incentives to encourage telehealth visits, particularly in conjunction with Annual Wellness Visits (AWVs). This is a great modality for focused conversation about annual health and wellness planning and confirmation of long-term conditions.
  • Identifying members and patients requiring support via telehealth for outreach
  • Supporting provider outreach through tools, scripting, and best practices. Layer in scheduling support for those providers that cannot address that on their own.
  • Conducting outreach to members about telehealth options to ensure they are primed when providers conduct outreach.

In Conclusion

While burdensome in so many other ways, a lockdown period is the prime time to take advantage of new telehealth opportunities that have been created by the pandemic, a time to close emerging care gaps that are likely being created by the crisis and resultant restrictions on access to care.

Where provider networks are not able to use telehealth, layer in telehealth in-home assessments for members. Also, include linkages with care management support as well as a battery of assessments related to SDoH that provide referral points.

COVID-19 appears to be a long-term challenge that may drive us through several transitions to and from opening up and closing down our society. In the near term, we can take steps like those outlined here for preparing us to maintain and even enlarge our effectiveness as RA professionals.

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