by Jon Rogers, Sr. Consultant, Risk Adjustment
As the fourth quarter approaches, managed care organizations (MCOs) should focus on optimizing their risk adjustment in-office assessment (IOA) processes to ensure accurate patient assessments, which are crucial for both appropriate revenue realization and quality care management.
The following comprehensive action plan outlines nine best practices that will enhance provider group performance, tailor engagement methods, and achieve coding accuracy.
- Review Performance-to-date by Provider Group
Conduct a thorough analysis of performance metrics for each provider group and assess several key parameters:
- Total Assigned Members/Patients (Patient Panel). The total number of members assigned to each provider group by the MCO and, most importantly, agreed upon by the provider group
- Total Assigned Members with Claims at Provider Group. The total number of members who had an encounter with provider group during the IOA program
- Total Completed In-office Assessments. The total number of in-office assessments completed by provider group. Best practice is for an MCO to clearly define what constitutes an IOA completion. Here are a few real-world examples of how MCOs may define an IOA completion:
- The attributed member is seen by:
- any provider in the group via a face-to-face visit
- their assigned PCP via a face-to-face visit
- a provider who evaluates a portion of historical and suspected conditions
- any number of providers who evaluate historical and suspected conditions
- Total In-office Assessments Completed In Their Entirety Without Coding Errors. The number of assessments completed without errors between the ICD-10 diagnosis codes on the claim and those supported in the medical record
- Total In-office Assessments Completed With Coding Errors. The number of assessments that contain discrepancies between the ICD-10 codes present and those in the medical record that require corrections
- The attributed member is seen by:
- Review Performance-to date By Individual Provider
A performance review at the individual provider level is recommended. This analysis helps MCOs pinpoint specific areas where providers excel or struggle, allowing organizations to tailor customized engagement strategies more effectively.
- Stratify Providers and Groups: The 2×2 Matrix
To streamline the IOA engagement strategy, it’s useful to stratify providers and groups into a 2×2 matrix based on the scope of membership and relative rate of engagement.
- High-volume, Low-performing Groups. For groups with a large patient panel but low performance, it’s best practice to conduct on-site visits (drop-ins or pre-arranged meetings). These face-to-face interactions can help MCOs understand barriers to performance and collaboratively develop action plans to enhance group engagement.
- High-volume, High-performing Groups. High-volume, high-performing groups should be acknowledged and appropriately incentivized to maintain IOA program engagement levels. Regular feedback and recognition can help sustain high performance; identifying and sharing best practices with lower-performing groups can foster a culture of excellence within the IOA program.
- Low-volume, Low-performing Groups. Groups with a small patient panel and low performance may benefit from alternative programs such as in-home assessments, telehealth visits or member engagement initiatives. Re-paneling patients to higher-performing groups may also be considered if the program allows. Many MCOs use imputed IOA group reassignments based on member-specific utilization trends.
- Low-volume, High-performing Groups. For these groups, ensure they have the necessary support to continue excellent performance. Mass communication methods such as emails or faxes can be effective without overwhelming IOA team operations.
- Perform Individual Provider Analysis
Performing the same 2×2 matrix analysis at the individual provider level within larger groups can further refine IOA program strategies. This granularity helps in identifying specific providers who may need additional support.
5. Review Coding Accuracy. Accurate ICD-10 coding is essential for correct risk adjustment and compliant IOA program incentives. The best practice for MCOs is to review medical records against completed and returned IOA forms to ensure coding accuracy. Any discrepancies should be addressed promptly to maintain data integrity and risk score accuracy
6. Reconcile Claims and Medical Records
Reconciliation helps identify gaps or errors that need correction, ensuring accurate reporting and IOA program incentive distributions. This involves:
- Claims Reconciliation. Verify that all completed IOAs have corresponding claims submitted to the MCO within an agreed-upon and reasonable timeframe
- Medical Records Reconciliation. Ensure that medical records from the IOA visit match the details in the completed IOA forms and medical claim
7. Explore Pros & Cons of IOA Communication Methods
Effective communication with provider groups is key to a high-performing IOA program. Each method has its advantages and disadvantages, and choosing the right approach can significantly impact success.
- Emails
- Pros: Convenient, can include detailed information, trackable, low cost, scalable
- Cons: May be overlooked or ignored, risk of miscommunication
- Phone Calls
- Pros: Direct and personal, allows for immediate feedback and clarification
- Cons: Time-consuming, may not be suitable for detailed information, scalability is difficult
- ‘Tagging on’ to Established Meetings
- Pros: Often a more efficient use of the provider group’s time
- Cons: May limit the depth of discussion, risk overloading agenda and not having the correct stakeholders
- Drop-in Visits
- Pros: A personal engagement approach which allows for real-time problem-solving
- Cons: Can be seen as intrusive and requires scheduling flexibility
- Fax Blasts
- Pros: Can reach providers who prefer traditional communication methods, immediate delivery, scalable
- Cons: Limited to text and simple graphics, may not be ideal for detailed information
- Letters
- Pros: Formal and official, can be detailed and personalized
- Cons: Slower delivery, may not be read promptly, increased cost of fulfillment and postage
- Implement Individualized Scorecards
Implementing individualized scorecards for providers can offer a clear, personalized view of their performance. This tool can help providers understand their strengths and areas for improvement, fostering a sense of accountability and motivation.
- Take the Next Steps
- Conduct Performance Reviews. Schedule and complete reviews of provider group and individual provider performance metrics
- Stratify Providers. Use the 2×2 matrix to categorize providers and groups and develop tailored engagement strategies
- Enhance Communication. Choose the most effective communication methods for each provider group and consider the pros and cons of each
- Ensure Coding Accuracy. Perform thorough reviews and reconciliations of medical records and claims to confirm ICD-10 coding accuracy
- Provide Individualized Feedback. Develop and distribute scorecards to providers and highlighting performance and areas for improvement
- Engage High-volume, Low-performing Groups. Arrange on-site visits or meetings to discuss barriers and develop action plans for improvement
- Support High-performing Groups. Recognize and incentivize high-performing groups and share their best practices with others
- Implement Alternative Programs. For low-performing groups with smaller patient panels, consider alternative programs such as telehealth or re-paneling
By following this best practice action plan, MCOs are equipped with a comprehensive and effective approach to IOA provider engagement, ultimately leading to better outcomes for members and their health plans.
ATTAC Consulting Group’s team of risk adjustment experts is dedicated to helping MCOs implement best practices, overcome challenges, and achieve outstanding outcomes for members. Reach out to ATTAC today to discover how we can assist in developing a compliant, high-performing provider engagement program.
