By Dustin Goossens
It's a Tuesday afternoon and your phone is ringing. It's been a crazy day with a large influx of patients, mounting paperwork, and constant interruptions. You answer the phone to hear a representative from one of your health plans on the other end of the line, wanting to arrange a time to come to your practice and copy medical records so the health plan can comply with Healthcare Effectiveness Data Information Set (HEDIS) requirements and create an accurate risk profile for the Centers for Medicare & Medicaid Services (CMS).
You schedule the appointment, but as you hang up, you wonder if this meeting is really necessary. Your practice generates detailed medical claims for this health plan every day, so couldn't they get the data they need from the claims?
This is a good question, and one with which many health plans and physician practices struggle. Both sides do not fully appreciate why medical claims cannot be used as an effective data source for HEDIS and risk adjustment. On one hand, some providers may think health plans are being unnecessarily thorough when they request to review medical records instead of claims. On the other hand, some health plans may think that if coders were trained more specifically on information needed by health plans, medical claims could offer more robust information. Both sides are incorrect because each is coding for different purposes and with different goals. Clinical coders focus on billing and revenue guidelines, while health plans are looking for specific, CMS required information.
The Variation in Information is Systemic and Currently Not Preventable
There is significant variation between the information a practice includes on a medical claim and the information needed by a health plan for determining risk adjustment and complying with HEDIS requirements. This variation is due to structural issues stemming from the different payment rules involved in reimbursing a practice for the services it provides versus adjusting health plan payments and premium rates. In fact, the data found on a typical office-based medical claim provides only about 40 percent of the diagnostic information available in the medical record.
By law, a physician practice can only code on the medical claim what services it provides during a patient encounter. If the practice adds more detail, it can inadvertently upcode the claim and be penalized later.
The health plan seeks to formulate a comprehensive picture of the patient's health overall and thus needs information on any chronic conditions, previous treatments, and so forth. Oftentimes, however, medical claims do not include this varied information.
Consider the example of a diabetic patient who comes to your practice to receive treatment for strep throat. When your coders create the medical claim, they include codes that relate to the care and treatment of strep throat. While the medical records document the patient's diabetes, the claim submitted to the payer does not indicate the condition unless the diabetes specifically relates to the treatment of strep throat. Your practice submits the claim and receives reimbursement for services rendered. A health plan, however, when reviewing information to establish risk profiles, is not as concerned with the strep throat diagnosis but instead wants to capture information about the patient's diabetes because determining the number of patients with diabetes in the health plan's membership is key to developing a risk profile that accurately reflects the health status of plan members. So, while your practice has generated a detailed and appropriate medical claim, the health plan is still missing essential information it needs. The only source for this information is the patient's medical record.
In addition, CMS requires health plans to recapture (or re-document) chronic conditions such as diabetes each calendar year. While the practice knows that the patient's condition is still present, health plans must re-verify this diagnosis each year. Hence, the health plan must perform retrospective medical record review-and come onsite to your practice to pull charts.
It's important to note that when a health plan comes to your practice to gather medical records, it is not to check up on your practice or look for inappropriate or inaccurate coding. The purpose is to gather data to generate a comprehensive picture of patients' health-data the health plan cannot get anywhere else.
Limiting the Intrusion
Although reviewing medical records is necessary, there are several ways a health plan or its representative can lessen the inconvenience of the process for your practice. For example, health plans do not have to come to your practice monthly to copy and look at medical records. Certainly there are different timeframes involved with gathering data for HEDIS and risk adjustment, however with a little planning, a health plan or its designated representative should be able to combine data requests and limit the number of times they have to visit.
Consider the example of a health plan that needs to collect information about patients with asthma to generate a complete risk profile. Before coming onsite, the health plan can also see which charts of asthma patients will be required to comply with HEDIS requirements and collect the relevant charts only once.
A health plan can also minimize the amount of time it spends in your office during each visit. By coding medical records offsite, a health plan or its representative can limit the intrusion on staff time and space. Electronically scanning records allows the health plan to quickly capture necessary information while leaving the time-consuming coding work for later.
Will it Always Be This Way?
Until provider and health plan payment rules better align, health plans will have to continue coming to your practice and reviewing medical records. Over time, however, providers and health plans can work together to identify ways to close the gaps between the data providers are allowed to include on medical claims and the data health plans need to be in compliance with regulatory requirements. Closing the gaps will take a significant cross-industry effort that will require compromise and collaboration. However, the resulting outcome will allow both health plans and physician practices to use the same data for payment and reimbursement, thus streamlining workflow and improving efficiency across the industry.
Dustin Goossens is a product manager at Outcomes Health Information Solutions
