Tools to Build Provider Partnerships – Best Practice Toolbox for Risk Adjustment Implementation, Part 2

Tools to build provider partnerships

Part two of a four-part series of CMS Best Practices Implementation

Centauri Health Solutions’ Director of Product Strategy – Dawn Carter

Looking to renovate your data submission program?

We want to help you expand your Risk Adjustment toolbox, so you can better construct and implement your data submission programs.

This is the second of four articles where I will reference 12 CMS best practices and provide actionable strategies.

In my initial article, I shared the first three tools – magic bullets for aligning internal and CMS edits.

This article focuses on creating a more complete data blueprint from the start, through stronger partnerships with your providers.

I recognize that this is no easy task. Providers focus most on caring for their patients, and rightfully so. However, it is possible to give providers concrete examples that link the quality of the data they send to the health plan with the quality of the care they eventually provide to patients.

CMS Best Practice Tool #4: Sandpaper

As any do-it-yourself handyperson knows, before you prime and paint, you need to get out the sandpaper. Assessing your organization’s tolerance for provider abrasion is an important starting point of provider partnerships. Let’s face it – asking providers to perform any additional tasks can certainly cause abrasion. However, to ignore the provider’s role in this process – in the interest of preventing abrasion – costs precious revenue.

The most effective way to address the quality of data received from providers, without setting foot in a provider’s office, is to ensure your claims system edits on inbound data mirror those of CMS.

When performing your root cause analysis of data that does not pass CMS edits, focus on the body of data with errors that are attributable to what the provider is sending – not what data fails due to your own systems limitations or incorrect data extractions.

A good example is value and occurrence codes. If you get errors stating that these codes are missing or incorrect for a given encounter scenario, double check – are you requiring the provider to send it?

If not, start doing that – and follow this checklist:

  • EDUCATE: Perform provider education so that they can do their own impact analysis and systems adjustments. Your provider relations department AND the person in charge of claims needs to do this.
  • ASSIST: Better yet, offer to help them do this – and the follow up – to ensure that the incidence of the error is decreasing.
  • INCENTIVIZE: Consider incentives for them to do this, especially if they have to make systems adjustments that will incur a cost.
  • DOLLAR DEMO: Equipped with the risk score impact in dollars and cents, talk to providers about what happens if they don’t comply. Money talks and people listen. You’ll need the help of your risk analytics team to do this, but this exercise will go further than any other to get the point across. Doctors are smart and will see that large amounts of lost revenue WILL affect the quality of care that members receive.

If you continue to experience issues with receiving data from providers, take a look in the mirror. Ensure that your own encounter data systems extractions are picking up the appropriate data and sending it correctly. If this is not happening, get out that sandpaper.

If this isn’t happening, whoever is responsible for those extracts needs to do that, be it your IT department or your submissions vendor. If you use a clearinghouse, be sure that you are receiving reports on data quality and quantity on a weekly basis at the very least.

CMS Best Practice Tool #5: Data Level

Using a level to ensure that items are hung correctly is an essential part of a toolbox. It is equally important to balance out your data, so that it is presented well. Compare RAPS and encounter data to understand the completeness of encounter data.

Recall that the EDPS data set is much broader than that of RAPS and includes services that were not historically sent for RAPS. Therefore, at the very least you first need to ensure that for every RAPS submission, there is a corresponding EDPS submission.

If there isn’t, you’ll need to do some investigation. I will explore that further in my final Best Practices article in this series. There are other risk adjustment analytics that are dependent upon the accurate transmission of both EDPS and RAPS, so this comparison is critical to identify submission gaps that affect risk scores.

CMS Best Practice Tool #6: Data Primer

Before you get out that paint brush – and set that data by submitting it to CMS – you want to take the time to prime your data. Make sure your data is ready by verifying chart review data.

This step is a bit harder because it will require the expertise of people in your organization who oversee chart retrieval and review operations. But the most important thing to consider is that any priming – or chart review data adhere to the following:

  • FORMATTING: Chart review submissions have some special formatting requirements for the X12 837 that clearly identify the submission as a chart review as opposed to a “regular” encounter. It is important to understand how to use these; otherwise, the encounter type switch for submissions on your MAO-004 are likely to be inaccurate and it could be hard to determine the ROI of your retrospective projects.
  • VALIDATION: If you are using external vendors for chart review and other retrospective projects, you need to ensure that these files are validated before sending them to CMS. They are validated against the same encounter rules as all other submissions.
  • ENCOUNTER MATCHES: Do not overuse the unlinked chart review option simply because you lack the resources or for some other reason won’t build the appropriate processes to attempt to find a match to a previously accepted encounter. CMS will eventually set a metric for this and does question submitters who are submitting only unlinked data.

To summarize, the blueprint for your project is dictated by the foundation of your provider partnerships. Work with your providers to assure data collection is happening according to plan. Keep in mind, there are additional resources to help you build those relationships and identify and eliminate encounter data gaps. Remember, using sandpaper, a level and primer on your encounter data before submission is part of the process; all of these tools within context are essential. Contact us today to learn how our consultative advisory approach can add to your CMS data toolbox.

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About Centauri Health Solutions

Centauri Health Solutions focuses on revealing care opportunities through its suite of products and services. Delivering data-driven services, through private cloud-based software solutions, the firm provides comprehensive data management designed specifically for risk adjustment and quality-based revenue programs, in addition to enrollment and eligibility solutions. Centauri improves member outcomes and financial performance for health plans, hospitals and at-risk providers by supporting initiatives in health care enrollment, risk adjustment, RADV risk mitigation, HEDIS and Star Ratings. Headquartered in Scottsdale, Ariz., Centauri Health Solutions also has offices in Cleveland, Ohio, Nashville, Tenn., and Orlando, Fla. For more information, visit