Understanding Provider Abrasion:
Healthcare is experiencing a pivotal moment once more. While there are ongoing changes from mergers and acquisitions and the blending of payers and providers, the instability is significantly reduced compared to previous years. Relationships have stabilized somewhat (as much as they ever do), and now disruption is occurring at a more granular level, diminishing the overall healthcare experience for over 1 million actively practicing physicians and 293 million Americans with health insurance.
Physician Abrasion Causes & Consequences:
Physician abrasion occurs when the payer-provider relationship strains, driven by conflicting business interests. Payer decisions on reimbursements and pre-authorizations affect physicians, leading to increased turnover and a subpar experience for both physicians and patients.
Business vs. Healthcare Goals:
Imagine being a healthcare provider overwhelmed with insurance company requests for medical records, diverting time from patient care. Repeated demands can lead providers to reject further requests, hindering data collection for risk adjustment.
The Problem: Provider Abrasion in Risk Adjustment Coding
When physicians spend an inordinate amount of time dealing with administrative burdens, their capacity to provide quality care diminishes. This situation creates a cascading effect where both the physician and their patients may decide to switch to an alternative payer, affecting the profitability and operational efficiency of the healthcare system.
How Provider Abrasion Can Impact Risk Adjustment Coding
Large volume & outdated workflow practices:
Physicians struggle to integrate payer and program initiatives into workflows, which often results in unrecorded diagnostic codes and disrupted provider office operations during on-site chart reviews.
Physician Burnout and Administrative Burdens:
Physicians face burnout and administrative burdens due to outdated manual processes and complex coding methodologies, worsened by the shift to value-based contracts tied to quality-based compensation.
Fragmented Data Access issues:
Fragmented patient data access hinders care coordination and frustrates primary care providers. Health plans need automated coding processes, integrated EMR systems, and better collaboration for efficiency.
The Solution:
Advanced Chart Review Processes AI-driven chart review enhances efficiency and decision-making, offering various improvements.
Time Efficiency:
AI in healthcare speeds up medical record reviews, saving 2.3 minutes per review, freeing professionals for critical decisions, while maintaining precision.
Accuracy and Consistency:
AI in healthcare ensures high accuracy and consistency in extracting medical information, reducing human error, and providing reliable data analysis.
Enhanced Decision Making (CDI):
Concise medical summaries enable better patient care decisions, especially in emergencies, enhancing overall patient outcomes.
Cost Savings:
Automating chart reviews saves time and resources, allowing healthcare providers to invest in technology, staff, and patient-centered initiatives.
Continuous Learning:
AI systems continuously learn from datasets, improving summarization capabilities and providing feedback for clinical staff training.
Enhanced Interoperability:
AI improves compatibility between patient information systems and EMR platforms, enabling smooth integration and widespread acceptance.
Easy API Integration:
AI-compatible APIs enhance integration and accessibility within the health-tech ecosystem, streamlining communication and medical data processing.
Challenges and Considerations in Implementing Advanced Chart Review Processes
The challenges can be divided into two key areas: 1) the dynamics between providers and payers, and 2) medical charting issues that providers must navigate to comply with health plan policies.
What challenges do healthcare providers face in their relationships with payers?
Unclear, Written Guidelines:
Specific, updated guidelines for accurate claim processing are either missing or insufficient.
Lack of Process Updates:
No timely communication about policy Changes to manage expectations.
Lack of Transparency about Denials:
Inadequate Denial Explanations & guidelines for resubmitting denied claims are unclear, hindering efficiency.
Poor Communication:
Proper coordination and communication channels to address denials
Delayed Payments :
No Timely responses to payment delays improper systems to expedite claims processing
Time-Consuming Unclear Processes:
Manual procedures & no clear guidelines for necessary manual data submissions to streamline processes.
Lack of Reassessment of Denial Reversal:
Denial reversals are not reviewed periodically to identify and address common issues.
Medical Charting Challenges
Let’s delve into some of the key obstacles healthcare professionals face in this critical task.
Time Constraints: Healthcare professionals and risk adjustment vendors face time constraints balancing workloads with accurate documentation, leading to incomplete or rushed entries, potentially compromising patient care quality
Data Overload and Entry Errors: The Risk of Oversights Health plans manage vast medical records, increasing data entry error risks. Mistakes can lead to inaccurate diagnoses, treatments, or medications, endangering patient safety.
Balancing Detail and Efficiency: Balancing detailed documentation and efficiency is crucial not only for accurate diagnoses and treatments but also for risk adjustment coding, as it helps to avoid information overload and ensure effective communication and workflow management.
Technical Issues: EHRs revolutionize charting but present technical challenges like system
glitches and slow response times, requiring robust IT support for smooth provider operations.
Insufficient Training in EHR Use: Proper EHR training is crucial for provider teams to avoid errors caused by misuse of features like copy/paste and ensure accurate and reliable documentation for health plans.
Lack of Standardization and Interoperability: Inconsistent charting practices and EHR system interoperability issues hinder accurate patient information interpretation and seamless data exchange, affecting care continuity.
How to Choose the Right Risk Adjustment Coding Vendors
Healthcare organizations should focus on key risk adjustment coding aspects to select vendors that enhance growth, compliance, operational efficiency, and patient care outcomes.
“Must-Have” Capabilities & Expertise for an Ideal Risk Adjustment Vendor
- Ability to Reassess Denial Reversals.
- Expertise in risk adjustment coding
- Automate Data Exchange
- Provide Insights and Analytics for process improvement.
- Satisfy Cost-Effectiveness and ROI
- Accuracy and Transparency
- Smart Process Execution and On-Time Deliverables.
- Interoperability and Chart Processing
- Training and Support Services.
- Privacy and Security Management
- Scalability and Flexibility in cloud-based operations
- Receptiveness to Changes
End Note:
In conclusion, addressing provider abrasion is vital for enhancing healthcare efficiency for physicians and patients. Administrative burdens, fragmented data access, and outdated workflows hinder quality care, causing burnout and inefficiency. Implementing AI-powered chart review processes improves time efficiency, accuracy, and decision-making, fostering a sustainable healthcare system. Choosing the right risk adjustment coding vendor with expertise, advanced technology, and robust support is essential for optimizing operations, ensuring compliance, and improving patient outcomes.
Nevertheless, Outsourcing risk adjustment coding helps providers focus more on patient care.
Published by: Martin De Juan
