In his white paper, Dr. Tony Kollarmalil, Medical Director, tells the story of Vee Healthtek’ risk adjustment work with a client. His white paper also covers the importance of an onshore team for meaningful collaboration.
Please click on the video to the right to learn more about the author, his paper’s key insights, and his motivation for writing on this subject.
To discuss this white paper at length, please contact Tony using his information provided at the bottom of the page.
Risk adjustment has been a mainstay of Vee Healthtek for the past several years. We have excelled at retrospective, concurrent and prospective reviews. Our HCC coders have abstracted codes for risk adjustment from medical records. Our clinical reviewers have combed through medical records, labs, diagnostic reports, consult notes and claims looking for risk adjustable chronic conditions that require physicians’ attention. The reviews by the clinical teams especially affect care of the patient, helping to identify overlooked conditions like diabetic complications.
The physician is then informed of these possible conditions as a part of pre-visit planning so that they can address them during a scheduled visit. Timely care of conditions like chronic kidney disease that we help identify is vital to stem the progression of disease that leads to better quality of life for patients. The accurate coding of these conditions also helps our clients receive accurate payments for the care of chronically ill patients according to their true acuity of illness.
One particular client that Vee Healthtek serviced for many years was provided onshore services in the areas of risk adjustment. They would provide us charts for risk adjustment retrospective and prospective review. In 2020, Vee Healthtek entered into an agreement for offshore retrospective and clinical reviews.
The client had a strong leader, an authority on risk adjustment. He had been our main contact for years and we had gotten to know him well through our onshore work. At the onset, he provided some guidelines that were particular to this clinical review project and not typically employed by our teams. He provided us with a manual he developed about coding and clinical reviewers.
Vee Healthtek was provided with a limited number of charts as a trial. After chart review, the team was to enter the identified diagnoses and evidence in the client’s web-based platform. For this project, we decided to employ a hybrid method where the reviews would be performed by clinical reviewers offshore and a quality audit would be performed onshore.
The point of contact would review 100% of all submitted work. Some of the challenges our reviewers faced was understanding the nuances of this project. For example, the clinical review team typically does not query for all diabetic complications. The point of contact had required we query for every possible complication even with minimal risk factors (such as age above 70 for peripheral vascular disease). The team quickly adapted to these changes.
Even with our vast improvements and capability to adapt, the client was not satisfied and was on the verge of deciding not to continue with the project, still in the test phase. A corrective action plan (below) was formulated, taking into account the major complaints from the client; some details were shared with the client, acknowledging some mistakes with promises to improve:
| Issue Identified By Client | Corrective Action Plan |
|---|---|
| Query for secondary hypercoagulable state based on RX of anti-coagulants | Team was told to query based on chronic, persistent, long standing Afib or other risk factors and never use RX as evidence. Acknowledge the case where reviewer missed replaced valve |
| Polyneuropathy unspecified is not an HCC | Team was told to avoid querying for non-HCC conditions. In case of clear evidence of polyneuropathy with specificity like alcoholism, query for the alcoholic polyneuropathy |
| No BMI cited for morbid obesity | Team has been told to cite the most recent BMI when querying for morbid obesity |
| In radiology report exact diagnosis is not being quoted | Team has been told to query for the exact diagnosis in the body or impression of the report |
| Page # being quoted in queries | The team was made to understand the difference between the PDF format they view vs the EMR in which the physician sees the charts |
| Verbiage like “Single PLT- 448 (H) abnormal, consider second test to be done after the first.” Instead keep it simple. | Team was made aware and this was rectified in the third batch. Replaced with “Single PLT- 448 (H) abnormal. Consider repeat test.” |
| Repaired AAA queried for | Acknowledge this mistake and the team was asked to pay more attention |
| ESRD patients not queried for dialysis status | Team has been made aware to query for Z codes even though the codes may be picked up by retrospective coding based on documentation |
| Lobar pneumonia from 2018 queried | Team has acknowledged this mistake |
| Acute diagnoses queried for | Team has been made aware to not query for conditions like VT in absence of continuous treatment |
| All diabetic complications are not being queried | The team was instructed to query for all possible complications and they implemented these changes in the third batch |
| Diagnoses based on risk factors are not being queried | The team was instructed to query for all possible complications. There has been improvement, but we will work on this |
| Medication not being tied to diagnoses | The team has been instructed to pay special attention to medications and query in case of medications without an assessment |
| Usage of F32.9 | Please advise on the tactic since we are unable to use a placeholder in Excelerate |
| Historical conditions being queried | Team was instructed to query for a diagnosis only if there is evidence of more recent treatment |
This corrective action plan helped the point of contact better understand our process and he agreed to send us more charts for review when we on the brink of losing the project. The onshore quality audit performed a 100% review of all work before the team submitted reviews to the client. This helped our offshore team better understand the client needs. We held regular meetings with the client and with our review team internally to help iron out any differences.
Before implementation of the corrective action plan, accuracy rate as per the client was not satisfactory. Once the new processes and workflow were implemented, the accuracy rate was increased to nearly 100% in some instances and the team received accolades from the client. The team was transitioned from apprentice status to full time clinical reviewers. The point of contact moved the project out of test phase into full time reviews. This project can bring us nearly 10,000+ charts for review. Our reviewers were entrusted with approving their own reviews and sending them to physicians with their comments.
We continue to employ this process as we add more reviewers to this project. The trust factor has increased multi fold and the client has granted us access to their EMR system. They have also requested us to review charts with a quick turnaround time of 72 hours for patients that have been scheduled for a visit.
We continue to improve the relationship with the client by having both on shore and offshore teams working in collaboration. Similar processes may also be implemented for future clinical review projects. With the phasing out of RAPS (Risk Adjustment Payment System), a method that relied mostly on retrospective review of charts for risk adjustment and the increased emphasis on EDPS (Encounter Data Processing System), prospective reviews will gain popularity and there may be opportunity for several similar clinical review projects in the future.
