Because of a rising number of risk adjustment audits and changes in HEDIS (Healthcare Effectiveness Data and Information Set) rules, providers should prepare for audit volumes to practically double in 2016. In fact, the National Committee for Quality Assurance (NCQA) estimates 2.5 million requests from HEDIS alone and another 6.5 million from health plans in the health information exchange market. 

Meanwhile, because of healthcare demand greatly exceeding expectations, losses skyrocketed across the nation for Affordable Care Act exchange health plans. For example, a prominent health plan in the Northeast recently reported an operating loss of $171 million during the first half of this year. Some health plans actually pulling out of the health insurance market completely.

With losses come recoupment efforts. Just as government payers have worked Recovery Audit Contractors (RACs) to take back reimbursements from providers, so too are the commercial payers trying to mitigate loss. Consequently, a higher focus on reviewing medical records for risk adjustment will be crucial to the health plans’ success. 

By reviewing medical records, the health plan is able to more quickly identify and better manage the patient’s chronic conditions, which generally results in lower cost of overall care.  Further the results of these reviews enable the health plan to more effectively manage premium costs or ensure accurate funding from CMS for the patient’s care.

Provider organizations must begin to prepare for additional audits and information requests in 2016. A flood of new enrollees, coupled with ongoing financial loss, spells a recipe for more health plan medical record requests in 2016. One area of specific impact is the change to the HEDIS guidelines that eliminates the rotating measure and drives the need for providers to produce more medical records.

NCQA and Measure Rotation: Impact on HEDIS Audits

NCQA recently notified health plans that it would retire federal guidelines 12 through 16 dealing with measure rotation. It didn’t request comment on this decision, which was made by its leadership team.

For more than 15 years, NCQA has allowed scheduled rotation of hybrid HEDIS measures; these measures allow medical record review. However, the increase in a plan's measure rate from chart review (hybrid lift) has declined. The hybrid lift in 2014 was far less than it was in 2000. Improved electronic and claims systems and better billing practices have resulted in more complete and accurate data. Most plans use supplemental data sources in areas where they previously relied on medical records.

Additionally, over the last 10 years, measurement has become a larger part of the healthcare-quality conversation. Although rotation was originally meant to reduce the burden of data collection, NCQA's experience is that the policy is not applied by plans as intended, resulting in unplanned consequences:

  • Rotation results in unequal burden and unequal opportunity to “choose the best rate” for organizations that must measure and organizations that choose to rotate.
  • Organizations sometimes report a rotated rate to NCQA and a current rate to the state regulators, which confuses customers and regulators who use the measures.
  • Reported results are a mix of performance data from the current and previous years, depending on how many plans choose to rotate, making interpretation of results difficult and complex.
  • Rotation affects benchmarks and skews measure trending, which affects all organizations.

This means that all requested HEDIS data must now be current. In most cases, substituting last year’s data in one or more specific areas to perhaps make the provider appear to fare better in reviews will no longer be allowed. This demand for greater timeliness increases pressure on providers—in more areas than one. Quality measures are also affected.
HEDIS and Quality Measures

In the past, there was only one type of risk adjustment model and only one payer affected—Medicare Advantage plans. Then, risk adjustments filtered into state Medicaid plans. Now, they also include commercial plans—individual insurance exchanges—which hit hospitals at the end of 2014.

HEDIS is part of a Medicare quality-improvement initiative with a clinical focus. Providers can choose whether to participate, but from a consumer perspective, it is critical. Commercial HMOs can also choose to participate, and about 90 percent do. The Centers for Medicare & Medicaid Services (CMS) requires participation for Medicare Advantage plans.

HEDIS data measures the services of various providers, comparing the qualities of plans based on type. Payers and providers ultimately have the same goals of improving Medicare quality and strengthening their bottom lines. They just approach these goals differently. While the hospital is focused on Medicare quality improvement, HEDIS is doing the same thing for commercial and Medicare Advantage plans.

With HEDIS and risk adjustment audits apparently on a perpetual rise, it’s time to maximize use of resources.

Getting Help with HEDIS

Providers have a limited number of staff and resources to process HEDIS and risk adjustment requests for information. Fulfilling each request in a timely and complete manner can be a huge challenge for health information management (HIM) departments. As a result, hospitals often turn to a release of information (ROI) vendor for assistance.

An audit relief program through a proven ROI vendor helps streamline HEDIS and risk adjustment requests from health plans.  The program may include a centralized request intake process for the provider, a centralized call center for the vendors or plans that are requesting these types of records, and the ability to ensure electronic delivery of the medical record images is established.

Security and HIPAA compliance should be guaranteed through the vendor as workload, phone calls, communication and red tape are removed from the provider’s plate. The program would report back to the provider in a timely fashion, thereby increasing efficiency.

After the ROI vendor delivers the medical records, the plan or its abstraction/coding vendor then delves deeper into the medical record. Looking at records with a fine-tooth comb often yields an average of a 20 percent higher return on diagnoses. This provides a payment bump, and helps manage comorbidity since Medicare pays a base rate, per member, per month. Each chronic condition documented boosts revenue. Closer identification of all comorbidities yields more Medicare dollars for the health plan and the provider. And, more detailed data helps health plans move patients into care plans specific to their chronic diseases.

Main Types of Health Plan Audits

HEDIS is just one type of health plan audit on the rise. Other audits generate additional administrative burdens for providers and can similarly be relieved through stronger relationships with ROI vendors:

  • DRG (Diagnosis Related Group) audits are performed to ensure cases are properly coded and that the information billed matches the information in the patient’s medical record.
  • Five-Star      Program (Medicare Advantage), CMS and NCQA measure the quality of health      plans. Health plans that demonstrate continual improvement receive a      better performance score.
  • Care      and Quality Improvement Plan audits target patients who are at a high risk      for developing certain diseases, with a goal of increased and improved      preventive care. Treating patients at lower costs benefits both provider      and plan.
  • Risk      adjustment reviews allows the plans the ability to identify if their      members have more risks, complications and comorbidities than submitted on      the claims.  Additional conditions      identified by the plan are subsidized by Medicare. 

As the number of medical record requests continues to escalate, it’s easy to see how an already disorganized and segregated audit management team could be completely overwhelmed. In planning for 2016, providers can expect even greater demands on HIM and audit management teams. Now is the time to ramp up or outsource accordingly.
Jeannie Hennum is senior vice president of the ChartSecure division of HealthPort, a provider of release of information technology, audit management technology and health information technology. Hennum is responsible for developing relationships between health plans and providers, as well as internal education on the importance of medical records to health plans.

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