Considering a technology vendor to support your next risk adjustment coding season? Here’s what to evaluate.

Major submission deadlines for Medicare Advantage (MA) and Affordable Care Act (ACA) risk adjustment programs are in the rearview mirror. We’re now entering a critical point in the annual risk adjustment activity cycle: The period where programs review and select new vendors ahead of the next high-intensity coding season. This year more than ever, it’s vital to make sure you have the right solutions in place to support your program’s scalability, accuracy, and overall performance in 2020 and beyond.

Whether you’re putting together a Request for Proposal (RFP) or simply researching vendor options on your own, this comprehensive list of evaluation criteria will help you determine whether a given risk adjustment technology vendor is a good fit for your organization's risk adjustment program goals.

Product offerings

The breadth and depth of product offerings are a key consideration for any technology vendor. Before onboarding someone new, your team should feel confident the vendor can support your program’s objectives and processes now and in the future. Here are a few important factors to consider:

  • Product mix: Does the vendor offer a variety of solutions that can solve multiple needs for your risk adjustment team? How much of its product portfolio supports risk adjustment activities versus other health care initiatives? While some companies offer a wide array of products, they don’t provide deep expertise in any particular area. Other vendors are more focused in their offerings but may not have a solution to support all aspects of your program. There are pros and cons to each scenario, but when it comes to highly-specialized risk adjustment coding technology, opting for vendors with focused expertise is generally better than choosing a one-stop shop.
  • Product maturity: Dig in to understand how robust and reliable a potential vendor’s technology solutions really are. If possible, take time to chat with a few references who use the vendor’s solutions to see if they’re the right fit for your needs. If you’re switching vendors, it’s even better to talk to another organization that made the same change to hear about its experiences.
  • Product roadmap: A risk adjustment technology investment isn’t just about what the vendor can do for you today, but how it can support you in the future. When evaluating vendors, ask for their product roadmap so you can see what new features and solutions are actively in the works. If your organization tends to adopt new solutions early, ask about product ideas that might be in early stages as well. There may be a good opportunity to co-develop a new solution with the vendor to address an unserved program need.

Implementation process & timelines

Implementation may be a one-time experience, but it’s still an important consideration. Every risk adjustment technology vendor has unique implementation requirements and timelines for chart retrieval, coding, auditing, and submission. If you’re looking to spin up a new technology solution for the second half of 2020, make sure your potential vendor is able to onboard your team, get the appropriate data and specs, and execute projects on timelines that align with your program requirements.

Additionally, some vendors include separate implementation fees that you’ll need to factor into your overall budget. Ask about these kinds of additional costs up front so you’re not surprised during contract negotiations.

Chart processing capabilities

Unlike manual coding shops, risk adjustment technology vendors don’t all handle diverse chart data with equal sophistication. Some vendors are really good at processing EHR extracts, but can’t process PDF charts well because they have limited optical character recognition (OCR) capabilities. Some vendors are highly skilled at processing PDFs, but fall down when it comes to repackaging and normalizing EHR data for coding purposes. You’ll want to select a vendor whose chart processing expertise aligns with your chart mix.

Another chart processing factor to evaluate is data loading. Can the vendor stream small batches of data through its processing pipeline, or does it need to run all the charts at once? Make sure to get clarity on this up front so you’re not stuck waiting on all of your charts to be processed at one time, compressing your coding and auditing timelines.

Accuracy & efficiency

Every risk adjustment technology vendor promises to improve coding accuracy and efficiency through some combination of data science (natural language processing, machine learning, artificial intelligence, etc.) and workflow technology. To validate a vendor’s claims, you’ll need to do a bit of digging.

From an accuracy perspective, it’s important to evaluate whether a vendor’s science is reliable—meaning, it doesn’t serve up a bunch of coding predictions that are incorrect, and it also doesn’t miss coding opportunities that are supported in the documentation. Reviewing case studies, running an Opportunity Analysis, or talking to current clients can help you get a reliable view of performance.

In terms of efficiency, workflows will have the biggest impact on coder performance, either positively or negatively. It’s important to understand how charts are routed, how much workflow customization the technology supports, and how evidence is surfaced for coder evaluation. Keep in mind that the most efficient workflows may not align with how your coding team is used to working, and therefore may require some expectation-setting and retraining as you implement your new solution. 

Coding experience

It goes without saying that any coding technology you adopt should make it easy for coders to review charts and enter coding information. But there’s more to the chart review experience than simply entering net-new HCCs. Some other factors to consider include:

  • Adds & deletes: Does the vendor support chart reviews for both adds (net-new codes) and deletes (unsupported HCCs)? Looking both ways is essential in today’s scrutinous regulatory environment.
  • Traceability: Does the vendor provide a clear audit trail for coding decisions? Is it clear who worked on which charts if corrective action needs to take place?
  • Performance tracking: Does the platform provide metrics on coder accuracy and productivity to help inform education and staffing decisions?

Platform scale & performance

Scale and performance reliability are two key factors to evaluate when considering a new risk adjustment coding vendor. In addition to asking the basic questions about uptime, scalability, and historical data processing experience, you should also ask about chart processing limits in terms of size or batches. Some vendors struggle with processing large batches of charts at one time; others may not have streaming capabilities to support ongoing chart submissions throughout a project.

Security & user management

Your security and IT teams undoubtedly have a specific set of security and user management requirements that new technology vendors must meet. Work with your counterparts to gather specifications so you can make sure any potential vendors are well positioned. In addition to the usual HIPAA / HITRUST / SOC2 compliance inquiries, you may also want to ask about user permissions and access controls, depending on your organization’s needs.

Reporting & analytics capabilities

One of the benefits of using a risk adjustment technology platform is the ability to gain deeper insight into performance, value, and population risk trends through reporting and analytics. While every program has its own set of KPIs, a few types of metrics you’ll want to ask about include:

  • Progress tracking: Does the vendor provide visibility into how much work has been done, how much is left to complete, and how much time is left before the project deadline?
  • Coder performance: Does the vendor track coder assignments, productivity, and accuracy? Is this information shared just with managers, or also with individual coders?
  • RAF value and distribution: How much value is being generated as a result of coded HCCs? What types of chronic conditions are most prevalent within your member population? Which providers have a high number of HCCs that were incorrectly coded at the point of care? Your technology vendor should be able to help you answer these important questions about your program.
  • Output reports: What kind of output report is provided? Can these reports be tailored to your specific organizational needs?

Choosing a new risk adjustment vendor is a big investment. By evaluating these criteria, you can make sure to select a technology provider that aligns with your program’s goals, requirements, and preferences.

Looking for a retrospective chart review solution? Apixio’s HCC Complete solution supports complete, accurate, and timely coding and audit projects for Medicare Advantage, Affordable Care Act, and Medicare Shared Savings Program submissions.