Now that all government-regulated health plans and provider groups are impacted by risk adjustment and quality improvement requirements, success with these programs is required for plans to effectively compete.

Most entities operating under risk adjustment or quality programs pursue comprehensive “boots-on-the-ground” strategies to augment their claims streams with additional data about the members.  It is true that abstracting medical records and performing in-home assessments can increase the likelihood that a plan will achieve premium accuracy or higher quality ratings.  However, boots-on-the-ground strategies are no longer enough (most Medicaid states do not support the use of retrospective medical record reviews). There are also other data leakages that cannot be addressed by typical patient-focused and/or chart-focused interventions.

As encounter data traverses the pipeline from the site of clinical care to CMS or a state government entity, encounter data containing diagnosis codes are being lost along the way.

Mile High Healthcare Consulting has identified for its clients many different sources of leakage, from trading partners that cannot accept the HIPAA-required 12 diagnosis codes on every professional claim, poorly formed encounter records that fail edits upon submission to the government’s encounter data system, use of outdated procedure codes that prevent triggering of HEDIS measures, to data warehouses that mangle capitated encounters by applying fee-for-service claims editing rules.  Our work has shown that health plans and provider groups are forgoing 3-5 percent of their premium revenue as a result of data leakages.

We all know that transparency is the best way to ensure accurate risk scores and premium payments.  But many plans and provider groups do not have real-time visibility into their risk scores at different points in the data pipeline.  Mile High has developed the solution.  Introducing Cortex-Scope, a component of Mile High Healthcare Consulting new Cortex-Data Warehouse suite of SaaS applications.  Cortex-Scope is the system that allows everyone who is responsible for maintaining or overseeing the risk adjustment process to see the contribution that is being made to the final risk score at every step of the data pipeline.  Cortex-Scope can even help “boots-on-the-ground” vendors to report ROI results to their clients better and faster.

Cortex-Scope represents a completely different approach to revenue management, an approach that augments the tried-and-true “feet-on-the-street” strategies.  Cortex-Scope calculates risk scores at every point of the pipeline, including from EMR data, unadjudicated claims, adjudicated claims, vendor data submission, submissions to RAPS/EDPS/EDGE/Medicaid, and acceptances that return from the government entity.

Risk scores can be updated and surfaced to a web application as often as the plan or provider group chooses to transmit data to Mile High.  You can also visualize the relationship between any two risk scores, stratified by a variety of different metrics.  Stratification variables include, but are not limited to, provider group, PCP, contract ID, product, zip code, and county.

Cortex-Scope is a SaaS application, linked to Mile High Healthcare Consulting’ suite of applications centered around the Cortex-Data Warehouse.  The Cortex-Data Warehouse collects, transforms, and analyzes data, making it available to all of the risk adjustment, quality measurement and population health apps. Users will access information.  The clients benefit from this approach because data only has to be transmitted once, in one format.

The time has come to improve your mastery of EDS data submissions.  Let Mile High Healthcare show you the way.