How to overhaul your approach to medical records review with EHR access
By Eric Hedrick
For over a decade, Medicare Advantage Organizations have been reviewing medical records to ensure diagnoses are appropriate and to the highest specificity for the member. But this process comes with challenges that can burden providers, lead to incomplete data, and be costly. The good news: Innovative strategies to EHR access are available to overhaul your approach to medical records review.
Leverage innovative technology to revolutionize your program.
With modern technology comes new opportunities, but not all solutions are equal. Use the switch from a manual to automated process to rethink your approach with new access to real-time clinical data. Why? Here are the benefits:
- Close gaps earlier in the year.
For most plans, medical record reviews take place in two large projects after the close of the calendar year. The problems: First, if you’re unable to close a gap, it’s too late to take any additional action. Second, gaps that were documented but not submitted on the claim in the first few months of the year aren’t known about until a year later, which potentially leads to increased spend on prospective outreach, or worse, a missed opportunity to provide access to disease management services. - Identify encounters that didn’t close gaps earlier in the year.
Members commonly have a single yearly visit. Once that visit happens, it’s valuable to know whether that encounter closed their HCC gaps. When you can confirm that a gap remains open, it allows you to pull them into programs that ensure their chronic conditions are appropriately managed while also closing the HCC gaps.
- Incentivize providers in close to real-time.
Providers aren’t coders, and we don’t want them to be. But with real-time EHR access, you can better support data exchange. Today you may be incentivizing providers to revalidate chronic conditions with attestations only to find out one month (or more) later that the diagnosis didn’t make it on the claim or wasn’t documented at all. With direct EHR access, you can review the documentation close to real-time and work with providers to close these gaps in the process.
- Stop paying MRR vendors to collect truncated codes.
There remain multiple steps in the claim submission process that can cause diagnoses coded in an encounter to be removed from the claim delivered to the health plan. You can see this in your claims data warehouse by finding providers that rarely or never submit more than four codes on a claim, and we consistently see this as a meaningful issue. The fifth through 12th diagnosis codes exist on the medical record today, and you’re likely paying a vendor $25 or more for a coder to collect those diagnoses when you could be automatically pulling them in with an EHR connection. - Restructure your coding support.
When you can review charts in real-time rather than saving them all for one large project, it opens opportunities to re-evaluate your coding resources. Maybe that means bringing the work in-house, or doing more targeted, real-time reviews.
Do less.
Yes, really. It’s likely most of the encounters you review today only benefit the coding vendor. Your partners should be analyzing your historical projects and augmenting future projects to help you identify those charts and save you those funds. And with automated electronic access, you can also run low-cost algorithms on the charts that will help you avoid allocating coding resources to work that has no impact.