TABLE OF CONTENTS

What Happens When Documentation Falls Short

The Common Challenges

How Health Plans Can Support Providers

The Benefits of a Proactive Approach

Building a Collaborative Future

Blogs & articles
Driving Compliance with Technology: A Path to Better Risk Adjustment Outcomes
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Clinical documentation compliance isn’t just a box to check—it’s a cornerstone of effective healthcare and risk adjustment. Providers and health plans both play vital roles in ensuring documentation is thorough, accurate, and compliant with regulatory standards. However, gaps in documentation can create challenges, from administrative inefficiencies to delayed reimbursements. Addressing these issues requires clear communication, practical tools, and a commitment to collaboration.

What Happens When Documentation Falls Short

Providers spend their days balancing patient care and administrative tasks. After back-to-back appointments, documentation often becomes an end-of-day task. This delay can result in incomplete or vague records. For instance, a provider might record that a patient has diabetes but fail to include critical details like diagnostic tests, treatments, or management plans. Without this additional information, the health plan lacks the context needed to ensure compliance with coding and risk adjustment standards.

 

Health plans rely on accurate documentation to meet regulatory requirements, but they also play a key role in supporting providers. When documentation is incomplete, plans must issue queries to clarify or request additional information. These queries can disrupt provider workflows if they’re unclear, overly complex, or misaligned with how providers prefer to work.

The Common Challenges

Several challenges stand out in the clinical documentation improvement (CDI) process including:

 

Incomplete Documentation: Providers might not include enough detail to support a diagnosis, leaving health plans to issue queries for clarification.

Workflow Disruptions: Queries that interrupt a provider’s daily routine can lead to frustration and delayed responses.

Technology Resistance: Some providers still prefer handwritten notes, which can slow down compliance processes and lead to errors in transcription or interpretation.

Regulatory Risks: Non-compliant queries, such as those perceived as leading or suggestive, can expose health plans to regulatory scrutiny.

How Health Plans Can Support Providers

Health plans have a unique opportunity to make compliance processes more seamless for providers. By focusing on solutions that fit into providers’ existing workflows, they can enhance collaboration while improving efficiency. Here are a few strategies:

 

Streamline the Query Process: Health plans should use technology to integrate queries directly into the provider’s electronic medical record (EMR) workflow. For example, UST HealthProof’s platform displays queries alongside the EMR interface, so providers don’t have to switch systems. This keeps the process simple and avoids disrupting the provider’s workflow.

Offer Flexible Engagement Options: Not all providers embrace technology at the same pace. Health plans should provide multiple ways to respond to queries, such as in-person engagement coordinators for handwritten documentation or document upload options for providers who prefer to mix paper and digital methods.

Focus on Clarity: Queries should be concise, neutral, and easy to understand. A poorly worded query can confuse providers and delay their response. Using standardized templates ensures consistency and avoids unnecessary back-and-forth communication.

Use Data to Drive Improvement: Analytics can help health plans identify patterns in provider documentation and queries. If a provider frequently omits information, health plans can offer targeted training or support to address the issue. This reduces the need for repetitive queries and fosters a stronger partnership.

The Benefits of a Proactive Approach

Health plans that adopt a prospective approach to risk adjustment see better results. By addressing documentation needs during the patient visit, plans reduce the need for retrospective corrections. This saves time and resources while improving compliance. For example, technology that flags missing details in real-time allows providers to capture all necessary information upfront.

 

Providers also benefit from faster turnaround times. Instead of revisiting a patient’s record weeks later, they can respond to queries while the details are still fresh. This reduces frustration and improves the overall documentation process.

Building a Collaborative Future

The most successful health plans recognize that providers are partners. Supporting providers means offering tools and processes that make their jobs easier—whether it’s integrating technology into workflows, providing flexible options, or offering educational resources.

 

UST HealthProof’s solutions align with these goals by combining advanced technology with practical support to offer an efficient documentation process that creates a compliant and collaborative healthcare system.