RISE News Nº 10 - Summer 2022
Kian Gohar
Ryan Brolliar
Melanie A. Prince
RISE West 2022 announces keynote, special presenters A health care crisis looms:
Inovalon’s Dr. Paige Kilian on the need to integrate quality and risk programs, improve provider engagement, and reduce administrative burden
Risk adjustment coding practices:
Wolters Kluwer’s Amy Campbell on clinical documentation compliance and how to bridge the language gap between coders and physicians
THE LATEST NEWS HHS launches Office of Environmental Justice to address environmental inequities in health
Medicare Trustees Report: Medicare Part A now has enough funds to pay benefits until 2028
CMS final rate notice: Medicare Advantage plans to see an 8.5% pay increase in 2023
HHS ends Trump’s controversial SUNSET rule
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Surgeon General Advisory lists 6 proposals to address health worker burnout and resignation
CMS issues the 2023 Medicare Advantage and Part D Final Rule: 10 things to know
OIG report: 1 in 4 Medicare patients harmed during hospital stays
HHS Becerra on COVID, upcoding in Medicare Advantage, and telehealth
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The RISE Value-Based Contracting Summit: Payerprovider conference offers roadmap to value-based health care delivery
Final 2023 Payment Notice for the ACA marketplace: Standardizes plan options, makes changes to risk adjustment models
OIG report on prior authorizations raises concerns about MA beneficiary access to medically necessary care
CMS proposes rule to create special Medicare enrollment periods
REGULATORY UPDATES
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HHS issues guidance on HIPAA and audio-only telehealth; OIG report recommends CMS improve race, ethnicity data to assess disparities; and more
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AHA calls for Justice Department to create taskforce to investigate MA denials; Study finds 10K seniors got unnecessary surgeries during first year of COVID; and more
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Medicare spending dropped 6% in 2020; Private insurers to pay $1B in consumer rebates
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Lowering age of Medicare to 60 could add $155B to U.S. debt; Becerra tests positive for COVID; HHS extends telehealth services in risk adjustment program; and more
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Medicare Part B premiums will likely drop—but not until 2023; Senate committee to review draft telehealth policies for mental health; and more
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Calls to ban ‘junk’ health plans; Record enrollment in ACA coverage; and more
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DOJ charges 21 with $150M in nationwide COVID-related fraud schemes
MA saves seniors $2K a year compared to FFS Medicare, study finds
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COVID-19 update: CMS announces end to some nursing home emergency waivers; Appeals court upholds vaccine mandate for federal employees; Study finds vaccines prevented 2.2M deaths in US; and more Americans are drowning in medical debt
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Beyond the data weeds: Analytics for stronger performance across the risk adjustment lifecycle
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Episcource
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I n fo r m a t i o n blocking enforcement: The impact on access to health information
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Wolters Kluwer
As COVID cases rise again, US renews public health emergency
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Home visits play a critical role in diabetes prevention and management for seniors Signify Health
CMS outlines action plan to advance health equity; CDC launches National Weather Servicelike forecasting center for infectious diseases; and more
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CMS finalizes decision on Aduhelm coverage during clinical trials; HHS to take part in easing medical debt; and more
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The risky business of risk adjustment coding and auditing GeBBS Healthcare Solutions
Millions could lose ACA coverage without extension of subsidies; 50M experienced health data breach in 2021; 3 takeaways on Medicare supplemental coverage; and more
READ OUR ENTIRE COLLECTION OF INSIGHTS AND ARTICLES
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RISE West 2022 announces keynote, special presenters The premier Medicare Advantage senior leadership conference will take place September 1-2, with preconference workshops on August 31, in Los Angeles. Here’s a look at the presenters who will take the main stage.
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Kian Gohar
Ryan Brolliar
Melanie A. Prince
RISE is excited to announce the keynotes and special presenters who will join the roster of RISE West 2022 speakers, September 1-2, at the InterContinental Los Angeles Downtown. The annual event will feature new ways to meet risk adjustment goals, keep up with the ever-changing Star Ratings measures, and explore the opportunities and complexities to come out of the pandemic—and what it means for 2023 risk and quality scores.
Gohar, a sought-after strategist and advisor, coaches entrepreneurs, executives, and leaders to make their impossible, impossible. He is the coauthor of the Wall Street Journal bestselling book, “Competing in the New World of Work,” the former executive director of the XPRIZE Foundation, and founder of GeoLab, an innovation research and leadership development firm.
The breakfast session is complimentary but additional registration is required.
The main conference will kick off Thursday morning, September 1, with a special presentation by Ryan Brolliar, founder and author of “The Music is Medicine Tour.” His latest book chronicles his tour across the entire United States playing music for people in need. He visited all 50 states, 78 hospitals, and more than 1,500 patients in nine months. Join Brolliar for a morning dose of inspiration and to feel better connected during a time when so many have felt more disconnected than ever before. Futurist Kian Gohar will follow with a keynote address on how to compete in the new world of work. He will offer research-led insights into using radical adaptability to win in a world of unprecedented change.
Join RISE Friday morning, September 2, for a special breakfast and panel discussion on how to empower women in health care. Hear stories from women who have succeeded in various sectors of health care and what can be done to further the impact of women in the industry. Panelists include DeAnna L. MinusVincent, MPA, chief social justice & accountability officer RWJBarnabas Health; Tracey Veal, DrPHA, MBA, senior advisory consultant, LA County Public Health Department; and Melanie A. Prince, MSN, BSN, RN, NE-BC, CCM, FAAN, former president, Case Management Society of America, retired military Colonel U.S. Airforce. Osato F. Chitou, principal consultant, NMOC Healthcare Compliance Consulting, LLC, d/b/a Compli by Osato, will moderate the discussion.
Prince will also take part in a fireside chat Friday morning, September 2, for her keynote on learnings from grief, grit, and focusing on the light at the end of the tunnel. Prince served 30 years in the armed services, retiring in the rank of Colonel assigned to Headquarters Air Force, where she was responsible for developing strategies to eliminate interpersonal violence in the military and advanced the Air Force Surgeon General’s global health care strategy. During her presentation, she will discuss lessons from her service, from rising to the rank of Colonels to working with Congress, insights from her experience in health care, and leadership lessons learned coming out of the other side of COVID-19. RISE West 2022 will take place September 1-2, with preconference workshops on August 31, at the InterContinental Los Angeles Downtown. Proof of a negative COVID-19 test or proof of vaccination is required to attend the live event. Click here for the preliminary agenda, registration information, and our health and safety protocols. ◆
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A HEALTH CARE CRISIS LOOMS: Inovalon’s Dr. Paige Kilian on the need to integrate quality and risk programs, improve provider engagement, and reduce administrative burden
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The health care industry is facing a crisis, warns the chief medical officer for Inovalon. Risk and quality measurement are major contributors to the administrative burden faced by physicians, which is causing them to leave the practice of medicine. And that means reduced access to care.
that found outpatient physicians only spent 27 percent of their day directly engaged in patient care. Nearly 50 percent of their time was spent on administrative matters. And the quality measure demands have only increased in the last six years, adding to provider abrasion, she says.
Paige Kilian, M.D., chief medical officer, Inovalon, calls herself an internist by training and a primary care physician at heart. It’s why she keeps doctor-patient interactions front in center in her role at Inovalon and the company’s role in the industry.
“The access to care is that physician-patient interaction,” she told RISE in a follow-up interview after the conference. “It’s that doctor-patient in the room, and the whole system is balanced on that interaction…I think of it as a big, inverted pyramid balanced on that interaction. And as we reduce that interaction, we take away the time and patient care…the foundation is shaken. So, I think access to care is really the crux of risk and quality.”
It’s also why she’s concerned about a looming health care crisis: The more the industry piles on the paperwork that physicians must complete, the more it undermines what they are there to do, which is to provide quality care to patients.
Everything depends on the physician being able to see the patient and that’s being undermined by demands from the industry, including meeting health plans’ need for physician documentation to validate claims, according to Dr. Kilian. It’s a vicious cycle leading to burnout, she says, compounded in the last two years by the pandemic and the loss of staff, inadequate personal protection equipment, and frustrations around vaccinations.
Dr. Kilian, pictured, expressed these concerns during a recent panel discussion at RISE National on how to integrate quality and risk programs. “You can see this accelerating,” While the industry has come to recognize the need to streamline quality she says, “and we need to get and risk programs, she says stakeholda hold of it. My strongest ers are failing to realize that the “fabric e n c o u ra g e m e n t t o t h e of our health care system is unravelindustry is that we view it as ing in front of us as we place more and more administrative burden on The industry was already facing the crisis that it is...” physicians.” These burdens are driving a doctor shortage prior to the panphysicians out of practice and demic. Indeed, a 2020 survey by the AAMC projected a ultimately reduces access shortfall of 139,000 by 2033. The toll of COVID-19 exacto care, she says. erbated these shortages and a January AAMC survey of 20,000 physicians at 124 institutions across the country She cites a 2016 study now finds that one in five doctors plan to leave medicine published in the Annals in the next two years and one in three is looking to reduce of Internal Medicine their available hours in the next two years.
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“You can see this accelerating,” she says, “and we need to get a hold of it. My strongest encouragement to the industry is that we view it as the crisis that it is. Yes, we have to achieve what we have to achieve in outcomes and measurement. But first we have to make sure that the doctor-patient engagement hours are available.
Small successes There have been small steps in approaches to integrating risk and quality departments that have helped address the issue, she says. Empowered physicians groups have driven some of this integration, insisting that health plans limit their interactions with them by sending a monthly list of all their requests. But not all physician groups have that type of relationship or standing with their health plans. “I’m also aware of provider engagement teams that have driven the engagement, the integration themselves, so risk and quality remain siloed in the organization, but they’re asks of the physician funnel through provider engagement. So, the provider engagement team serves as the integration point,” she says. These approaches provide a more efficient process of getting information to health plans, but it also addresses the urgency of reducing the administrative burden on doctors. “It’s critical to coordinate this outreach to doctors with clear messages, showing them the value in what they are being asked to do,” she says, citing tasks like prior authorization and quality metrics. If physicians have the perception that they are being asked to do something that poses no value to their patients or themselves, they won’t buy in to the demands, Dr. Kilian explains. “When health plans provide clear, streamlined message to docs with evidence of the value that’s being
achieved, they’ll be far more successful,” she says. “Docs need to see that patient care is being improved by this, outcomes are being improved by this, and also what the financial benefit is to the docs themselves.”
Actions for health plans Dr. Kilian acknowledges that solving the problem isn’t easy, but she does have suggestions to help health plans begin to address the issue: • Recognize the urgency of the problem for health care delivery and the industry as a whole • Commit and prioritize the move to integration of risk and quality—if teams are too territorial about their roles and a complete merger isn’t possible, at least consider combining the data output, using the same tool or platform, or combining the messaging • Provide clear communication to physicians with the value of the ask “Plans need to show doctors, this is why we’re doing this, and this is what we’ve achieved. Thank you for your contribution. Here’s what we’ve accomplished so far and here’s where we are headed. I think that kind of messaging will go a long way toward engaging doctors in a process that they are a bit skeptical with at this point,” she says. Since most health plans don’t do an effective job of communicating these messages, Dr. Kilian says a health plan that shows its value and offers physicians financial incentives will capture their attention. “A physician or practice has very limited time to engage. If you don’t capture their attention, they’re going to prioritize other matters. Give them a reason to prioritize you.” ◆
“A PHYSICIAN OR PRACTICE HAS VERY LIMITED TIME TO ENGAGE. IF YOU DON’T CAPTURE THEIR ATTENTION, THEY’RE GOING TO PRIORITIZE OTHER MATTERS. GIVE THEM A REASON TO PRIORITIZE YOU.” 8
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RISK ADJUSTMENT CODING PRACTICES:
Wolters Kluwer’s Amy Campbell on clinical documentation compliance and how to bridge the language gap between coders and physicians
RISE caught up with Amy Campbell, R.N., MSM, CCDS-O, clinical documentation integrity director, Wolters Kluwer, Health Language, one of the speakers at the recent Risk Adjustment Forum, to discuss coding challenges and strategies to improve compliance of clinical documentation. Campbell, a nurse for more than 30 years in the critical care setting, has built outpatient clinical documentation improvement (CDI) programs across the country, collaborating with and teaching providers, payers, and health information management partners about compliant chronic condition capture. She moved into the tech industry in 2021, joining Wolters Kluwer, Health Language, to help develop clinical natural language processing tools and content for use in risk adjustment clinical diagnosis validation.
Common challenge: The language conundrum One of the most pervasive challenges that coders and physicians face is that they speak two different languages, Campbell said. A coder’s workflow is based on what is documented in the CLICK TO SEE OTHER ARTICLES
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physician’s note within the medical record. Coders can only code if there is enough information in the record to document a diagnosis. Physicians aren’t taught to code and don’t understand the coding language. Campbell uses the example of a stroke. If the patient had a stroke a week ago, providers may consider that a recent stroke. But for the coder, the patient has a “history of” stroke as soon as he or she leaves the hospital.
Relationship building is vital before physicians can buy-in to the process, Campbell said. “So much of what I do or have done in the past is relational,” she said. “I need to have a relationship with that provider very similar to when I was caring for the patients, so that they trust that I am going to do what they’ve ordered me to do. I’m a support person, so to speak. That role doesn’t change a whole lot when it comes to CDI. I am still a support person.”
This miscommunication not only causes frustration between providers and coders, but it can also become a compliance issue. The Office of Inspector General (OIG) targets areas where there is inconsistency, particularly where communication gaps exist, Campbell said. “They are targeting areas where clinical practice differs from coding practice, including how that coding language works.”
If physicians trust that support person, it’s easier for them to understand that the CDI specialist is there to ensure that the care the patient receives is documented and the query is justified. Where a coder can only look at a singular encounter, a CDI specialist can look elsewhere in the chart to pull out information that may indicate another condition. For example, if a CDI specialist sees a patient is receiving dialysis, he or she can ask the physician, was this an emergency or is this long-term due to end-stage renal disease?
Population health and social determinants of health are two areas that could become compliance concerns, she said. While providers are becoming aware that there are non-medical conditions that impact people’s health and are beginning to ask patients about them, if the information isn’t in the note, the coder can’t code it. “So, providers may be asking questions to get the information, but oftentimes it’s not in a format that the coders have access to,” she said. This is an example where CDI can be helpful because the clinical documentation specialist has clinical and coding experience and can pull those two languages or two worlds together. The specialist can clinically validate whether a condition exists and if the specificity is in the record to capture the diagnosis.
Common challenge: Physician buy-in But what if a physician doesn’t believe in the CDI program? Physicians don’t receive training on clinical documentation in medical school so it’s common for some providers to resist these programs as an added hassle and unnecessary work. 10
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The key, she said, is not to ask leading questions. The work is not to only find the diagnosis but to find the information in the note that supports that diagnosis, Campbell explained, noting that the validation is also helpful for payers. “It would help the payer to establish a case for this diagnosis to say, ‘I have the diagnosis here, but then I also have all these clinical indicators that support this diagnosis.’ So, it’s clinically validating that diagnosis, not just data validation where the diagnosis is present.” Once it’s determined the condition was present in the past and you have supporting information, Campbell said a payer could potentially use it as a basis of a query to the provider to ask whether the condition is still valid or viable. And if that is the case, the payer can ask the physician to please include any valid or viable conditions they addressed in the note for the upcoming visit so that they can better understand the treatment plan or what the provider saw that supported the patient’s diagnoses.
Strategies for compliance Whether your organization is just thinking about creating a CDI program or struggling with compliance issues, Campbell offers four best practices: 1. Do the pre-work before launching a CDI program: Review a sample of records to find a few areas to focus efforts on for measurable change. Show how improving documentation in these areas would benefit the patient, practice, or population. Educate providers before establishing a program. “They need to understand the administration values their skills and time, but there is value in the program; we need to find a way to work together and work smarter,” she said. “They need to understand that nobody’s asking for them to work harder. Oftentimes that’s their perception. So, it does take a little bit of time.” 2. Find a physician champion: Having a respected physician who understands the goal of the program is “the golden chip” to launching a successful program. This person supports the mission of a CDI program and can promote it to colleagues. 3. Review the record prior to a patient visit: A clinical documentation specialist can review the medical record in advance of the office visit to assess for suspect or outstanding conditions and compliance opportunities. “This prospective view is a little more forward thinking than traditional coding and lends itself to having a more clinical person in the role.” 4. Set up processes: Establish a policy that calls for a CDI specialist to review the bills with targeted codes prior to submission to ensure the code is appropriate. If there is a question, the CDI specialist can determine if the documentation supports this diagnosis, or not and changes the code as needed. The ultimate goal is to accurately capture the patient’s story and resources provided during their visit within the boundaries of compliant coding. ◆
UPCOMING EVENTS Webinar: Risk-Adjustment: How to Navigate the Medicare Market July 12, 2022 1:30 PM ET
RISE West 2022
August 31 – September 2, 2022 InterContinental Los Angeles Downtown | Los Angeles, CA
HCC Coder User Group (Meeting 5)
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September 22, 2022 1:00 PM ET
HCC Coder User Group (Meeting 6)
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Oct 18, 2022 2:00 PM ET
The 12th Annual HEDIS® & Quality Improvement Summit October 25 – 26, 2022 Luminary Hotel & Co. | Fort Myers, FL
The 20th Risk Adjustment Forum
November 28 – 30, 2022 Fairmont Scottsdale Princess | Scottsdale, AZ
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