Shifts in the risk adjustment landscape have put greater emphasis on the accuracy of diagnosis data. One of the main strategies deployed by managed care organizations is to build out robust two-way retrospective coding programs that add missing ICD10 diagnosis codes and delete erroneous ICD10 diagnosis codes. Here are three key areas to review in order to pinpoint what’s working well and where there’s room for improvement:
- Review historical retrieval rates by methodology and provider groups. Successful retrieval of medical records is paramount to the overall success of the retrospective program. Most payers obtain medical records through a variety of retrieval channels including email, fax, paper, portal upload and EMR access. Reviewing each channel’s retrieval rate provides insight into what’s working well and opportunities for improvement. Drilling down into the mechanics of the retrieval channel and the current processes aids in identifying issues that need to be addressed, including incorrect provider locations, timing and follow up, as well as duplicate chases.
- Analyze coding accuracy performance by provider groups for trends. Completeness and accuracy of ICD10 coding may vary significantly between rendering providers and provider groups. Objectively comparing the coding results at the provider level from past chart reviews may help shape future medical record review strategy. Additionally, these insights can pinpoint providers for focused and customized ICD10 education efforts.
- Quantify missing or potentially erroneous conditions not targeted on chase lists. Medical record review targeting is often aided by insights and recommendations from in-house analytics or analytics vendors. These insights often come in the form of recommended member and provider combinations to chase. Although these target lists are highly actionable, they may be too narrow in scope. Here’s a helpful exercise: Take a step back and view all open and potentially erroneous conditions associated with members who have had a risk-adjustable encounter in the calendar year to see if there are opportunities that fall outside of the initial target list.
Contact ATTAC’s industry experts for additional insights on how to implement best-in-class strategies for upcoming retrospective chart review projects.