Changing the conversation around appropriate risk coding for value-based care

Risk scoring is one of the most important parts of value-based care, yet it’s also one of the least talked about. Stakeholders tend to stay relatively tight-lipped on the topic of identifying and coding patient health risks since it’s the one area of value-based care that remains less-than-ideally aligned across the patient-provider partnership.

A patient’s risk adjustment factor (RAF) score records his or her medical complexity, which is directly tied to clinical performance and financial incentives. A higher risk score may lead to larger per-member payments for managing that individual and enhanced rewards for meeting targets, while a lower score indicates that the patient is healthier and therefore should cost less to care for appropriately.

In an ideal world, there would be a robust, shared framework for risk coding and standardized, widely adopted technologies for recording a patient’s diagnoses, complications, and the socioeconomic factors that may influence treatment. However, the industry is still at the beginning of navigating these processes.

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As it stands, sometimes payers may believe providers are being overly generous with their Hierarchical Condition Category (HCC) coding, while providers might feel as if payers are underestimating the clinical complexity of their attributed patients.

Finding the appropriate balance isn’t always easy, especially among patient populations with above-average clinical needs.  To consistently and accurately identify risks, providers need access to technologies that enable precise and efficient documentation without over- or under-coding.

At Crozer Keystone Health, a four-hospital health system serving areas of Pennsylvania, Delaware, and New Jersey, this type of appropriate risk coding is top of mind, particularly in the home visit complex care program.

“The challenge with risk-based models is that they are, well, risky,” says Jason Keiner, DO, Director of Complex Health. “The amount of money we receive from our payer partners is directly related to the patient’s complexity on paper.  If we do not document complexity, there is no other way of showing that they are above average risk, and that can be problematic in the value-based care setting.”

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The process of treating patients in their homes can further complicate the issue, said Keiner.

“With home-based visits, we have several providers seeing the same patients at any one time,” he explained. “We need timely and transparent communication between those providers so they can treat the patient in a coordinated, holistic way.”

Crozer Health works with its solutions partner, CareAlign, to help providers navigate the home care environment while ensuring the health system can perform well in its Medicare shared savings contract.

“Technology that makes documentation easier helps us with all of our shared goals,” said Keiner.  “For example, it allows us to pay more attention to patients during these visits. By making it easier to code while spending more time talking to the patients, providers can juggle the multiple demands on their time and attention while accurately documenting the patient’s medical concerns.” 

“We found it helpful to bundle diagnoses and their complications so we can track a single problem and its sequela in one grouping. We can pull prior assessments and plans, manage tasks, and bundle the condition and its complications efficiently. This helps us keep track of the patient over time.  As a result, we are improving communication, making it easier to understand how the patient’s risk status is changing, and enabling accurate risk coding.”

With more time to assess patients thoroughly, understand their challenges, and document accordingly, Keiner’s RAF scores have essentially doubled, he noted.

Without any context, this claim might raise some eyebrows for payers. But the explanation reflects well on Crozer’s efforts rather than otherwise.

“HCC coding is all about developing processes for chart review and appropriate condition identification,” Keiner explained. “Demonstrating that our RAF scores increased after training our team on appropriate HCC coding doesn’t indicate that we were seeing sicker patients, but that we’ve gotten significantly better at identifying the chronic conditions and complications that accompany familiar diagnoses.  That allows us to provide better, more proactive care for our patients, which is exactly what value-based care is designed to enable.” 

While there may always be a gray area between appropriate coding and potential overbilling, neither payers nor providers should assume that the other is trying to cheat the system. On the contrary, risk coding offers yet another opportunity to work together in an evidence-based, collaborative manner to ensure patients are getting all of the services they need.

“Our team tends to operate very academically, and we have long discussions at our weekly huddle about tricky coding situations,” he said.  “When we are on the fence, we reach out to our system’s coding experts or other clinicians experienced in this area of work.”

“It is essential to act with integrity, which is what we always strive to do.  As clinicians, we do not see financial incentives as a direct result of higher risk scores. Rather, we see them as a validation that we are, in fact, caring correctly for our patient population and delivering value for the health system.”

Jennifer Bresnick is a journalist and freelance content creator with a decade of experience in the health IT industry. Her work has focused on leveraging innovative technology tools to create value, improve health equity, and achieve the promises of the learning health system.