Trusted vendor relationships are crucial for Managed Care Organizations (MCO’s) to deliver outstanding service, care and value to members, providers and regulators. These relationships, which are foundational for successful risk adjustment programs, provide prospective in-office and in-home assessments, extra bench strength on retrospective projects, data submissions, audit support and analytics. With increased scrutiny by CMS and OIG, there is a greater focus on diagnosis codes submitted to CMS that are a direct result of vendor activity. It’s imperative that MCOs have the right controls, oversight and monitoring in place to ensure accuracy of vendor-generated data submitted to regulators.
The experts at ATTAC Consulting Group have identified four areas to consider prior to vendor contract negotiation:
- Coding accuracy service level agreements (SLAs). Coding accuracy thresholds are common within the risk adjustment space. Standard SLAs include >95% coding accuracy in many contracts, but the particulars of how and when the 95% threshold is calculated are where the real risk exists. OIG and CMS trends point towards higher scrutiny on supplemental data submissions and in-home assessments. It’s time to review and evaluate whether your organization’s risk adjustment SLAs are in alignment with OIG and CMS best practices.
- Internal vendor oversight and monitoring. Internal processes and controls for vendor relationships are just as important as contractual SLAs to maintain effective and compliant risk adjustment operations. Regular overreads of statistically significant samplings are critical to be confident with the quality of vendor deliverables. It’s imperative to have the right sample sizes, frequency, and timing of overreads throughout the year to quickly pivot if trends appear that need to be addressed. Up-to-date and in-depth policies and procedures that are reviewed annually is a cornerstone of a high-functioning and robust risk adjustment function.
- Best-in-class technology and platforms. Health plans need significant time to fully evaluate whether the potential operational drag and disruption associated with changing risk adjustment technology, platforms or vendors is worthwhile. Proven technologies that have survived and passed the early adopters phase are worth investigating for large-scale implementations. Recent case studies have shown that robust monitoring, stringent oversight and a thorough vetting process are the gold standard for driving risk score accuracy.
- End-to-end data submission continuity. It’s critical to ensure complete and accurate data submissions to EDS, EDGE and state regulators to realize accurate risk scores and monitor key performance indicators throughout the data processing continuum. Depending on the arrangement, vendor data may come through as normal clearinghouse claims data, flat files, supplemental data or other formats. Regardless of how the data is received, it’s important that all records are present and diagnosis data is complete and accurate.
ATTAC has the expertise and experience to keep accuracy of risk scores in the forefront of your organization’s risk adjustment program. With a pulse on the latest CMS and OIG trends, ATTAC is uniquely positioned to aid in your vendor oversight and contracting strategy. Reach out to learn more about how we can help you implement effective and compliant risk adjustment programs.