Unlock The Potential of Prospective Programs

As more and more provider organizations enter into risk-sharing agreements, provider engagement programs are experiencing a surge in participation. Provider engagement programs improve the collaborative relationship between plans and providers to keep documentation up-to-date for CMS submission. It's essential for plans to offer a variety of delivery methods to suit the provider's practice. Some practices enjoy an in-person, on-site method to receive personalized guidance for education and to maximize documentation opportunities, while other practices enjoy an EMR-integrated solution for a highly efficient digital workflow. Providers with an already established process for responding to queries may prefer a remote option via fax. The important aspect of a healthy provider engagement program is not necessarily the delivery method but rather the timely and continuous communication between plans and providers to close gaps on addressable conditions.

Tune in to discover the best practices for running a successful provider engagement program.

Host: Today we’re talking about Unlocking the Potential of Prospective Programs with Michelle Calagaz. Michelle is an expert in prospective risk adjustment programs and specializes in provider engagement tactics. Welcome Michelle.

Michelle: I’m excited to be here and talk about prospective programs with you.

Host: Michelle, in risk adjustment CMS needs to receive information about the health of a member so the appropriate resources can be assigned for each member’s care. We were talking offline earlier and you brought to light an important point—that there’s a lot of confusion in the industry about the role of prospective programs versus what’s discoverable in a retrospective program. Will you clarify some of the points of confusion you see between prospective and retrospective programs?  

Michelle: Yes, I find that there’s a lot of confusion about the expectations of prospective programs. In order to realize the full potential of prospective programs, I think it’s important for providers and plans to understand what is prospective, what’s retrospective and how the two compliment each other in a holistic program. Prospective is looking forward- something that is likely to be or an outcome that is expected.  Retrospective is looking backward into the past.  Both pieces are used in the CMS Risk Adjustment world. You may hear the term retrospective review.  That is when the medical records of past experiences, codes, health are reviewed Whereas a prospective review is reviewing the current status for the health of the patient as of today. In a CMS risk adjustment world, we have to paint a picture of Mrs. Smith to CMS. CMS is not going to come down and see Mrs. Smith, they can only see what’s in the data and they’ll assign resources to Mrs. Smith on that data. So, let’s say Mrs. Smith had controlled diabetes last year but this year it’s gotten worse, now it’s uncontrolled with neuropathy. If CMS only has the retrospective information, Mrs. Smith will look fairly healthy with controlled diabetes.  But by adding the prospective component, CMS will receive new information on Mrs. Smiths current state providing a full picture of Mrs. Smith’s health.

This information has to be captured in the documentation so CMS can assign more resources (i.e. money), but if that information never makes it in the documentation or a claim, CMS isn’t going to know and the plan isn’t going to get the appropriate resources to pay for Mrs. Smith’s progressing condition. And if CMS doesn’t provide the correct resources, then the health plan will lose money and that’ll impact premiums, making them higher, or Medicare copays may increase. Every year, we need to capture the current picture of heath for each member through a prospective lens.  

Before we move on, let’s talk a little bit about how providers get paid. There are two main categories, fee-for-service and/or risk agreements, In a typical fee-for-service market, the provider has a contract with the payor. The provider puts the services they provide on a claim and the health plan pays the provider according to the contracted fee schedule. For example if you look at an EOB, explanation of benefits, and you may see the provider’s office charged $1000 for a service but the health plan’s fee schedule only allows for $600. The provider doesn’t get the 1000 they charged, they are reimbursed the 600 defined in the contracted fee schedule.  

Now with risk agreements, the provider organization and health plan agree to share the risk of expenses for a patient population.  The provider/organization will receive a percentage of the premium revenue and are responsible for medical expenses for those members.

Keeping the patient well decreases costs. So if there’s revenue over and above the member’s care needs, that’s kept by the provider organization. However if the care expenses exceed the revenue, the provider owes money back to the plan.  This shared responsibility requires the providers to document, follow the treatment plan, and follow up with the patient to increase adherence to the treatment plan. This model promotes patient centered care and redefines the relationship between providers and plans as a collaborative effort which prospective programs support very well.  

Host: Earlier you mentioned that risk agreements were favorable for prospective program success. Can you elaborate on this idea?

Michelle: Sure, prospective programs support managing the care of the patient’s current state.  Risk sharing payment models mirror this idea and encourages complete documentation of current conditions.  Most prospective programs will request feedback on current diagnosis of the patient by obtaining documentation to confirm, “yes, this condition still exists, or this condition still exists and has worsened, or no, this condition is no longer present.” If the condition isn’t documented, it doesn’t exist and is considered an open gap.  

Host: How can health plans best support providers to document and follow through with patient centered care?  

Michelle: So, the most effective way for plans and providers to work together is a plan-sponsored provider engagement program. This maintains an open line of communication to ensure both sides are working together to keep the documentation up-to-date and provides a path to CMS submissions.  

First thing, is to present the providers with any open gaps to confirm whether last year’s historical conditions still exist. This has to be done each year in a prospective program. Then, we might also sprinkle in some opportunities/suspects about conditions that have never been coded for Mrs. Jones but we think she may have because the retrospective analysis of her medical record data suggests it. The suspected conditions are discovered in the retrospective review process we already discussed..going backwards to identify instances that suggests a condition exists but in this case it wasn’t documented. Once that suspected condition is identified in the retrospective program, it can be included as a suggested open gap and captured in a prospective program. This information gets put onto a form we call a CDI alert (Clinical Documentation Improvement alert), and we ask the provider to address the open gaps with the member at the next visit. It’s important to realize, a response on a CDI alert form provides information for 1 day, the day of the visit.  

Another thing, the CDI alert is not to be mistaken for merely printing out a form with generalized suggestions or screenings. You know the patient is 70 years old and here are a bunch of conditions that occur frequently in this population. It’s not that. This is specific to the member—specific codes and diagnoses the member has had on claims or data from pharmacy or labs that indicates what a member may have. The other key thing to mention is that this form is an actionable activity that the provider can use as a guide. Notice I said ‘guide’, the form is not a medical record. It’s a guide for the provider, saying here’s what the data is indicating, can you address these conditions and document it in the medical record? The provider is the expert, the health plan offers insights from a bird’s eye view of the CMS documentation requirements.

Host: Is there a best-practice for how to structure provider engagement programs?  

Michelle: In terms of delivery, there’s no best practice. It just depends on what’s best for the provider’s office. But in terms of the program itself, successful programs need to have continual communication, timely responses, and deliver specific and actionable feedback to providers. Let me elaborate.  

The idea of using a form to present gaps to a provider is not new, however, in the industry we’ve seen programs that may present the form to the provider in a manner that may not be truly prospective. In some cases, the provider receives 300 forms at the beginning of the year and by the end of the year the forms are supposed to be returned. The intent of the program is undermined because there’s no opportunity for communication or actionable feedback and it’s not timely—it’s occurring way after the office visit. Some programs have general feedback in the form of an annual report. The report might say, “We found 200 cases of controlled diabetes and we found that 50% were actually uncontrolled.” That’s not particularly helpful. There’s no action to be taken. How does this translate into improved documentation practices at the individual member level at the time of the visit?

That’s a key phrase: at the time of the visit. We want providers to document and close gaps at the time of the visit. We want the provider to return the forms within 14 days of the visit. We’ve seen in the market there’s no industry standard timeline for when the form should be returned: by the end of the year or when the member is seen next. That’s a broad range. So, again, in order for this to truly be prospective, it has to be timely and we feel returning the form within 14 days accomplishes this. A further point to add is that we provide feedback in the form of queries within 7 days. That way if we see any documentation opportunities or have questions, we sort it out within a reasonable timeframe. There’s an unspoken industry standard that is generally accepted that CMS frowns on addendums to medical records after 30 days. Think about it like driving over the speed limit. If the speed limit is 30 and you’re going 31, technically you're still speeding but it’s not likely you’ll get a ticket. But if you’re going 45 your risk of getting a ticket increases. Similarly, medical records can be addended within 30 days of the visit without an increased risk for CMS audit. Again, this is not a written rule but this is how we came up with our 14 day sweet spot for receiving back a CDI alert. This gives us 7 days to review it and if there is an addendum required, we’re only 21 days in from the date of service. There’s still 7 days to change the medical record. This timeline seems to support the maximum benefit for prospective programs.

Host: We’ve talked about the importance of timely and continual communication in provider engagement programs. Let’s talk about the queries and how specific feedback is a valuable part of prospective success.  

Michelle: Great question. Let me illustrate how this works. Every January a CDI alert gets put in front of the provider. That’s when all gaps reopen and need to be documented for the new year. So, the provider needs to indicate what conditions still exist, if any new conditions have emerged, and if there are any dropped conditions. Let’s say the provider addresses all the conditions, documents and submits the response.  

Let’s say the medical coder reviews the CDI alert response and has a question. They see that controlled diabetes has been marked as present on the CDI alert, but the medical record states some complications. The coder sends a query to ask the doctor to document the complication. The doctor gets the query and addends the record to add the patient has developed neuropathy.” Now there’s a new code submitted and the member has more resources from CMS for the treatment of neuropathy. Then it goes back through the same cycle, next January, the CDI alert will ask he doctor if the patient still has diabetes with neuropathy. This will continue each year for recoding.

The specific feedback that was delivered in a timely manner enabled us to capture the complete picture of Mrs. Jones for this year. You have to realize, every year, the member is a blank slate, like one of those color by numbers coloring sheets they give kindergartners. At the beginning of the year, there are no colors on the sheet. Throughout the year, the doctor is coloring in the different numbers on the sheet with conditions. And by the end of the year, there’s a full color picture to give to CMS. CMS provides the resources for whatever picture the health plan gives them—whether it’s got one color filled in or whether it’s a completely colored picture. So if the member doesn’t come in, claims don’t get coded, the provider doesn’t document appropriately or colors in the wrong colors: CMS can only pay for the colors they see.  

Host: That makes sense. Earlier you mentioned that the delivery method didn’t matter as long as it fit the operational structure of the provider. Let’s talk about the different ways these programs can be delivered.  

Michelle: So, we try to match the practice with the right type of provider engagement for them. There’s in-person, electronic, and remote. Some practices really enjoy the in-person provider engagement because they have an on-site, weekly or biweekly touch point with the same person. The practices that prefer this method value the relationship and personalized guidance to maximize education and documentation opportunities. This is a paper-based delivery model and has the highest level of oversight. It works really well for providers that want to maximize the benefit of the risk sharing agreement.

Then there’s electronic provider engagement. This is a technology solution that integrates with the practice’s EMR system. The benefit here is that the CDI alerts are integrated into the provider’s already existing workflow so it’s very convenient to capture documentation opportunities at the time of service. This works great for providers that are excited about embracing technology and workflow efficiency.

If the practice doesn’t feel they need much guidance and they’re hesitant about EMR integrations, then there’s a remote support option. This is great for practices that have an already established, formal operational process for returning CDI alerts and responding to queries. But it’s the lowest level of support, so it’s not recommended for practices that are new to provider engagement or don’t have a formalized process is continuous and timely. The other 2 options have a return rate of over 75%.  

Host: Are there any statistics on how provider engagement programs improve risk scores?

Michelle: Yes, the average plan will see between a 10 - 15% risk score improvement and an average Star Rating increase of 5%. Closing gaps on addressable conditions has far-reaching affects on quality of care and member outcomes, so you’re going to see that reflected in the numbers.  

Host: That’s fantastic and I’m sure rewarding to know that these programs are having a ripple effect on a plan’s population health.

Michelle: It is rewarding and energizing.

Host: Michelle, thanks so much for joining today.  

Michelle: You bet.  

Host: If you enjoyed this episode, please leave a review on Apple or Spotify, and share this episode with your colleagues on LinkedIn.