Artificial Intelligence Ensures Payer, Provider Pay Covers Costs

Artificial intelligence (AI) in healthcare is influencing the next generation of radiology tools and helping to expand access to care in underserved or developing areas. The technology is supporting clinical advancements, but a Pennsylvania-based health plan is finding that AI can advance care management by ensuring providers and payers get paid the appropriate rate for treating their sickest patients.

“Artificial intelligence modules help us improve documentation, risk adjustment models, and financial payments, as well as level out the playing field so health plans are getting paid appropriately for the disease burden of their population,” Gateway Health Plan’s Gabriel L. Medley recently told RevCycleIntelligence.com.

Gateway Health is a managed care organization that serves more than 500,000 members across six states. The plan prides itself on delivering personalized care to each member through disease management, health and wellness programs, and preventative care.

Risk adjusted payments are key to ensuring the health plan and its network of 35,000 providers and 300 hospitals receives accurate reimbursement for delivering comprehensive, personalized services.

“What's happened in the last decade or so is risk adjustment was integrated to capture the disease burden of the population,” Medley, the VP of Quality Improvement and Risk Adjustment Programs stated. “Members can live in different areas and geographical landscapes, but the larger the membership, the greater the spread of the risk pool from an insurance perspective.”

“However, if you don't know the disease burden of the population, you could be incurring costs above what the base model presents,” he added.

While health plans are the recipient of risk-adjusted payments from Medicare and Medicaid, those payments trickle down to the provider level through better rates, Medley explained. Gateway Health can offer their providers reimbursement rates that cover a greater portion of the total costs of care because the plan is getting the right capitated payment from its public payer sponsor.

With risk adjustment now a critical component to health plan and provider payment determinations, accurate and complete clinical documentation is a top priority for health plans and providers alike.

Providers need to make sure documentation and coding accurately capture a patient’s conditions, and health plans must ensure the documents they receive from providers do not miss a condition or disease that would require spending above the payment rate.

“If a provider group is under-reporting diagnosis codes, that would mispresent the disease burden of the population and the health plan would get a lower risk adjustment,” he said. “If the health plan is getting a lower risk adjustment, this means you're not getting paid at the level that would cover the medical costs.”

Health plans are capturing the disease burden of their member populations primarily through diagnosis codes from encounter claims generated by their providers and hospitals. But the remaining 40 percent of information is found through chart coding and reviewing supplemental documents.

Chart coding and reviews are a major challenge for busy health plans. Not only do health plans need to employ expert coders, but those coders need to sift through thousands of charts to ensure providers did not miss a code.

“We have chart collection for unconfirmed diagnosis codes which tells us we have all these claims coming through, but we're still seeing information that may not be in the encounter claim that may still be sitting in the provider's EMR,” Medley explained. “In that case, we would go back to the provider and ask them to give us the chart for that member.”

“Then, a certified professional coder or certified risk adjustment coder would code that information and it would be converted into a supplemental encounter record. We then submit it to the government, state or federal,” he continued.

For some plans, like Medicaid arrangements, the process is even trickier because the payer does not accept encounter claims. Health payers must submit a new claim to Medicaid to correct the disease burden.

“At the end of the day, a health plan is still extracting information from the EMR in some form,” he stressed. “Everything's coming from the EMR and then turned into an encounter record and submitted.”

The complex process of ensuring the disease burden and other characteristics are accurately captured for accurate reimbursement troubled Gateway Health. Going into provider medical records, manually reviewing charts, and hiring expert coders to complete claims was complex and did not guarantee the health plan could paint a complete picture of their member population.

The managed care organization turned to an automated solution from Apixio that used artificial intelligence technology to streamline risk adjustment and ensure the plan and its providers received payment rates they deserved for treating an entire population.