How Health Plans Can Combine Quality Improvement and Risk Adjustment Efforts

June 12, 2019 Jeanette Stern

Medicare Risk Adjustment and Stars quality measures are both administered by CMS.  However, they are both very different processes. Risk Adjustment is the method used by CMS to pay Medicare replacement plans for their members' future utilization.  Stars measures are quality related goals for plans.  Meeting Stars goals means a substantial bonus for the health plan.

Both Risk Adjustment and Quality measures are equally important to health plans.  There is some overlap in the requirements for these two processes.  Because of that overlap, plans can combine their efforts and meet goals for both through certain activities.  Doing so takes planning, but offers good return on investment.


Health Risk Assessments

There are a few good strategies for combining Quality and Risk Adjustment goals in Health Risk Assessments (HRAs).  First, plans should choose an HRA provider carefully.  To combine goals, a provider needs to bring an array of services to the table.  In order to close gaps in care during an HRA, providers need to have access to lab equipment.  For hbA1C gaps, HRA clinicians can usually bring equipment pretty easily.  Other gaps that can be closed during an HRA are slightly more nuanced, like diabetic retinopathy. This test can be done in the home, but the results are often read after the visit.  

While the HRA clinician is closing gaps in care, they are also collecting diagnoses for Risk Adjustment.  Some Quality metrics may also be under-coded conditions.  For example, having a BMI calculated is an important Quality metric.  Morbid obesity is a risk adjustable condition.  BMI can be calculated during an HRA.  If the BMI is in the morbid obesity range,  the clinician can diagnose morbid obesity.  The diagnosis code for that condition can then be submitted to CMS for Risk Adjustment purposes.

You can even combine HRAs and post-hospital discharge visits.  Post hospitalization visits are great Quality tools. The visit can reduce hospital readmissions, which is an important Stars measure.  If the post-acute visit includes medication reconciliation, that may meet requirements for another Stars measure.  Depending on a plan's outreach strategy, post discharge assessments can also include gap closures.  Finally, the clinician performing the post-discharge visit can code any applicable conditions for Risk Adjustment submissions.

Plans and HRA providers benefit from combining efforts into fewer assessments.  The HRA provider saves time on scheduling and logistics. The plan benefits from reduced member abrasion.  Instead of performing two or three visits, members schedule just one.


Chart Reviews

HRAs are great ways to close Quality gaps.  They're also good for Risk Adjustment, but they only collect diagnoses codes for the next payment year, not the current one.  To increase Risk Adjustment revenue for the current payment year, plans often conduct retrospective chart reviews.  Medical records can be coded for conditions that a member has, but that have not been recorded on a claim.  Plans can also use chart reviews to ensure the accuracy of their submissions to CMS, as well as to close gaps in care for Quality measures.

Both Quality and Risk Adjustment chart reviews can be targeted to maximize ROI.  Often, Quality deadlines come before Risk Adjustment ones.  That means that Quality teams begin chart retrieval first.  After Quality Teams have finished collecting and reviewing their charts, Risk Adjustment teams can code those charts if it is within their budget.

Combining Risk Adjustment and Quality efforts isn't always easy.  It takes careful planning.  It also helps to have a partner who has expertise in both.  MedXM is able to customize their solutions to a health plan's needs.  That means it's easier to combine Risk Adjustment and Quality metrics.  For more information, contact us.

Previous Article
How Can Healthcare Enhance Customer Experience?
How Can Healthcare Enhance Customer Experience?

Next Article
Improving Your Member Engagement Strategy
Improving Your Member Engagement Strategy


Request More Information

First Name
Last Name
Thank you!
Error - something went wrong!