19 Feb Off
By Richard Schamp, MD
Multiple risk adjustment models are active across the US healthcare landscape. If you are reading this, you probably already live in a risk-adjusted payment world. For example, the Centers for Medicare & Medicaid Services (CMS) uses a risk-adjusted model that pays PACE and Medicare Advantage plans based on a person’s demographics and age, with additional payments made per qualifying diagnosis. States may establish a risk adjustment program using different methodologies for their Medicaid capitation payments. In addition, states may propose alternate risk adjustment methodologies for commercial insurance.
In addition to different models of risk scores, payers can specify the type of encounter a physician must document to capture a condition. CMS and some state-based exchanges require a face-to-face encounter, while other state exchanges allow video visits. Some self-insured plans allow telephone encounters or other forms of communication. Medical record documentation to meet requirements for payments has never been so complicated, and EMRs may compound the problems.
We know providers’ thought processes and habits initially developed in a fee-for-service context and might not translate easily to risk-adjustment documentation and guidelines. We are certain that the continuing shift of payment models now requires that providers develop additional competencies in clinical documentation to thrive, if not survive, in the burgeoning risk-adjustment universe. These competencies are not typically gained in academic training settings.
So how can a provider develop good clinical documentation competency? Like any new proficiency, there are components of knowledge, skill and attitude involved. Each component comes with its own challenges. At Capstone, we are committed to helping clients overcome those challenges so providers can achieve clinical documentation excellence. Our formula of using repeated clinically-relevant training with auditing and data collection to monitor progress and provide feedback has been enormously successful in helping to motivate providers to change their behavior.
With physician burnout at an all-time high, supporting your providers in gaining competencies relevant to success in a risk-adjustment payment universe can be crucial.