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:
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.
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:
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.
In the spring of 2018, Tessellate integrated with a sister company to form a stronger, more competitive organization, with the ability to leverage complimentary products and services and deep industry expertise. Recently, the company unveiled its new brand, Advantasure, with the tagline: Fueling Accelerated Performance.
The new name and tagline accurately reflect the company’s unique suite of technology products and business process services that improve the performance of health plans and provider organizations in the delivery of government healthcare programs.