Quality Rating System (QRS)

In a recent blog post, Can “Big Data” help address the challenges of risk adjustment,”we looked at why risk adjustment is critical to the successful implementation of value-based payment models. But risk adjustment models rely on timely and accurate provider data, and many health plans don’t have the systems and processes in place to efficiently capture the right data points, relying instead on manual, labor-intensive processes. As a result, health plans face the following challenges related to organizational efficiency and provider network satisfaction.

Data Silos
Health plans typically have multiple departments that are responsible for collecting provider data for different purposes. One department collects data for risk adjustment purposes, another for care management, another for HEDIS and Stars, and so on. Once data is captured, it’s maintained within these individual departments, rather than being centrally stored and accessible across the health plan’s various teams. The inability to easily share data within the health plan and among providers represents one of the greatest obstacles to maximizing the use of information and enhancing collaboration with providers.

Provider Abrasion
When a health plan’s data isn’t integrated and centrally stored, it creates problems for the provider network. Multiple health plan employees from different departments must contact providers—via phone, fax, and in-office visits—to request the same medical records for different purposes. It’s a source of frustration for providers, who often have to dedicate significant financial and administrative resources to respond to these duplicate requests.

RADV Audits
Conducted by CMS, Risk Adjustment Data Validation (RADV) audits ensure health plans are not overstating how sick patients are in order to receive a higher risk-adjusted payment. The audits check to see if Hierarchical Condition Category (HCC) codes submitted by Medicare Advantage and ACA health plans are supported by the member’s medical record. When health plans are notified of an audit, they must gather the records of the identified members, and once again providers are on the receiving end of multiple requests for documentation.

Addressing these challenges starts with a different approach to provider data capture.