Identifying and quickly closing member gaps is critical for risk score accuracy and optimizing member health outcomes.
Comprehensive risk adjustment programs work to close current-year gaps prospectively, identify suspected conditions, and look back retrospectively to identify historical conditions that were documented in previous years but not in the current year. Timely closure of gaps in care—from health plans to providers and members—is critical to a successful healthcare system.
“The quicker you can close the member gap, the faster the health plan can get reimbursed from CMS, enabling members to retain competitive and affordable premiums, timely care, and access to a robust provider network.” – Abe Chaya, Managing Director, Product Management
How to Close Gaps in Care—Fast:
Natural Language Processing
In risk adjustment, Natural Language Processing (NLP) identifies existing gaps in care. It predicts suspected member conditions by scanning data streams such as medical records, dates of service for pharmacy claims, medical claims, lab values, and clinical test results. In the past, medical coders parsed through the data manually to generate a chase list. Leveraging technology has proven far more efficient, accurate, and timely. With NLP, the chase list is produced automatically and submitted to medical coders for medical record review.
Electronic Medical Record Retrieval
When health plans and providers collaborate and connect systems, electronic medical record retrieval allows evidence to be discovered quickly.
Electronic Queries
Medical records are also run through the NLP engine to identify prospective gaps and indicators of suspected conditions for the medical coder to review and submit to the provider via a CDI alert. Although CDI alerts may be delivered and processed in person or via hybrid models, the electronic CDI alert has yielded the fastest gap closure timeframes.
Provider Participation
The ability for providers to close gaps at the point of care improves clinical workflow efficiency by delivering CDI alerts within the provider’s EMR. It delivers real-time actionable clinical insights about patients’ open risk and quality gaps.
At the end of the month, CMS requires submission of evidence to issue payment every month for the health plans to get reimbursed. The faster plans can turn around these submissions, the faster they can:
Using technologies such as NLP, electronic medical record retrieval, and electronic CDI alerts expedites the end-to-end process for risk adjustment.
How is your plan working to improve gap and chase timeframes? Connect with one of our risk adjustment experts, and let’s talk about challenges and solutions.
