Navigating the Complexities of Risk Adjustment: Insights from Katie Sender, VP of Clinical and Coding Services at Cotiviti, Inc.

In the ever-evolving landscape of healthcare, risk adjustment has emerged as a critical component for ensuring accurate coding, regulatory compliance, and effective communication between payers and providers. As the Vice President of Clinical and Coding Services at Cotiviti, Inc., Katie Sender, MSN, RN, PHN, CRC, plays a pivotal role in guiding organizations through the intricacies of risk adjustment. With over 25 years of healthcare experience, Sender’s leadership is instrumental in optimizing client outcomes and service delivery.

The Importance of Risk Adjustment

Risk adjustment is not merely a regulatory requirement; it is a vital process that impacts the financial health of Medicare Advantage (MA) plans and the quality of care provided to patients. The Centers for Medicare & Medicaid Services (CMS) and the Office of the Inspector General (OIG) have heightened their scrutiny of risk adjustment practices, necessitating a proactive approach from payers. The recent January 2023 rule from CMS, which eliminated the fee-for-service adjuster from risk adjustment data validation (RADV) audits, has intensified concerns among MA plans. This change is projected to recover over $4.7 billion in overpayments over the next decade, underscoring the financial stakes involved.

Key Components for Successful Risk Adjustment

To navigate the complexities of risk adjustment successfully, Sender emphasizes three key components: ongoing training, streamlined record retrieval methods, and the integration of advanced technologies alongside human expertise.

1. Improving Coding Training and Best Practices

Achieving better risk adjustment outcomes begins with a commitment to ongoing training and proactive planning. Many organizations underestimate the importance of regular coding training, which is essential to keep pace with the ever-changing regulatory environment. Continuous training not only ensures that coding remains current but also allows for real-time adjustments based on audits and data analysis.

Sender advocates for a culture of continuous improvement, where organizations regularly assess their coding practices and provide feedback to providers. This approach not only minimizes coding errors but also prepares organizations for potential overpayments. With OIG audits identifying millions in risk adjustment overpayments due to inaccurate coding, proactive planning is crucial for financial stability.

2. Streamlining Digital and Traditional Record Retrieval Methods

As healthcare transitions from paper to digital records, the journey has been gradual. While a significant percentage of providers have adopted electronic health record (EHR) systems, many still rely on traditional methods for record retrieval. Sender highlights the importance of standardizing data enrichment processes to improve accuracy and efficiency in record retrieval.

By collaborating with providers and streamlining communication, payers can enhance their record retrieval efforts. This involves understanding provider site mapping and maintaining effective contact methods to ensure timely access to medical records. The goal is to minimize administrative burdens while optimizing data accessibility, ultimately leading to better risk adjustment outcomes.

3. Assessing Priorities for Artificial Intelligence

The integration of artificial intelligence (AI) into risk adjustment practices presents exciting opportunities for improvement. Sender emphasizes the need for organizations to assess their infrastructure and identify areas where AI can enhance efficiency. Natural language processing (NLP) is one promising application, allowing coders to quickly identify key phrases and suggest related codes within extensive medical records.

Partnering with high-performing analytics teams can further streamline record retrieval efforts. By leveraging historical data and targeting specific providers, organizations can ensure that coding gaps are addressed effectively. This strategic approach not only mitigates risk but also enhances the overall quality of care provided to patients.

Conclusion

As the healthcare landscape continues to evolve, the importance of effective risk adjustment cannot be overstated. Under the leadership of Katie Sender, Cotiviti, Inc. is at the forefront of helping organizations navigate the complexities of risk adjustment through ongoing training, streamlined record retrieval, and the integration of advanced technologies. By prioritizing these key components, payers can enhance compliance, improve financial stability, and ultimately deliver better care to their members.

In a world where regulatory scrutiny is increasing, the insights and expertise of leaders like Katie Sender are invaluable. Her commitment to optimizing clinical and coding services ensures that organizations are well-equipped to meet the challenges of risk adjustment head-on, paving the way for a more sustainable and effective healthcare system.