Enhancing Value-Based Care through Precision Coding

Welcome everyone to today's webinar presented by the experts here at a PC Business Solutions and Summit Medical Group. My name is Cordell Hammond, and I'm gonna be our facilitator today. Before we get started at just a couple of housekeeping items, The conversation today will be about forty minutes followed by a Q and A session, where we invite you to participate by submitting questions for our presenters to address at the end. As attendees today, your line is muted.

So use the Q and A module to to ask those questions and please not the chat module. That way, we can just keep them all sorted. We'll be sending the slides and a recording of this presentation out in the following days. So keep an eye out for that.

Also, as mentioned, when you registered for this event, the webinar has not been approved for any CEUs.

And with that out of the way, welcome everyone to this afternoon's webinar, enhancing value based care through precision coding. Are thrilled to have our friends at Summit Medical Group join us to talk about how your organization can strengthen your value based care program with certified risk code risk adjustment coding. Today's presenters are Rachel Kuhn, Ed Curtis and Lee Williams.

Ed is the chief executive for summit group where he's responsible for all operational aspects, including practice, acquisitions, and integration.

Finance, human resources, value based care, legal information technology, practice support, and development, and diagnostic and therapeutic services. He is a certified medical practice executive with a business administrative degree, from West Virginia University. And has completed the Graduate School of Credit and Financial Management at Dartmouth College. Prior to joining Summit, Curtis was chief operating officer at Haddiesburg Clinic, where he developed the strategic plan and tactical initiatives to open a sleep and spine center in fusion clinic and breast cancer breast center of awareness.

And he led the turnaround of a multi specialty ASC. He's also served as the negotiator for physician contracts, with several hospitals and oversaw the clinic's conversion to new electronical medical records software. In addition, Curtis led clinical operations for the Department of Surgery in Medicine at three ASCs, as well as an ancillary service, and served as the clinic's privacy officer.

Rachel Cohen serves as the director of risk adjustment at Summit Medical Group and as an experienced educator and CMS risk adjustment and ICD ten centimeters coding and documentation guidelines. She has a proven track record of developing relationships and working physicians to improve documentation and streamline office workflow processes skilled in physician relationship, relations, medical compliance, ICD ten centimeters, risk adjustment, coding documentation, and health care management. And she has over twenty years of experience in the medical field, Rachel has served in a wide array of healthcare settings and roles in multi specialty practices regarding compliance, medical coding, and billing.

As an ahima, NAAPC approved ICD ten trainer, she has an extreme passion in helping others learn about medical coding and documentation compliance as well as helping medical professionals become certified coders. Rachel spent three years in Dubai and Abu Dhabi, working with the UAE government to create and implement coding methodology for medical facilities and providers. Co founder of the, Abu Dhabi AAPC chapter. She also served as chapter president promoting coding compliance and training.

And finally, Lee Williams is the director of education at AAPC. Lee has over twenty years of experience working in both the outpatient and inpatient setting. As an independent health care consultant, she has provided coding oversight services to organizations such as the centers for disease control and prevention, US consumer product safety commission and industrial economics. Her background encompasses coding, CDI, auditing physician training, and education, practice management, and compliance.

And with those introductions, I am thrilled to turn the time over to Rachel.

Hello there.

I think we wanna go ahead and go to the next slide.

This is our disclaimer just saying that we don't supersede a physician's judgment, but, this is for educational purposes.

And with that, I'm gonna turn it over to, Ed, who's gonna talk a little bit about our organization.

Welcome, everybody. Glad that you're with us. It was rather surprising to see I think we've got the entire country covered right now. I haven't seen any states yet that are not represented, so I'm sure AAPC's happy about that and so are so are we. A little bit of background about Summit Medical Group, founded twenty plus years ago with thirty seven independent minded primary care physicians.

We've currently expanded from primary care to pediatrics rheumatology.

And next month, We no. Two months from now, we will be adding, ophthalmology and retinal specialists. Go ahead.

Some of the details of Summit Medical Group and see we, you know, what our central lab does, eight eight point eight million lab tests last year, annual prescript I like to give everybody a visual of that. If you think about it's not been too long ago that we were handwriting script prescriptions, And now we have two point seven million of them that are being done electronically.

I just think of how many, you know, trees we've saved and also how tall pile those pres no prescriptions would be right now. Last year, we had one point four million patient encounters.

And we have over four hundred providers.

Go ahead.

This is one of my favorite sayings. I use it on almost every time I I have a discussion about value based care because we have to be able to learn how to pivot.

And my favorite quote there, I love reading it because it really reminds me about what we have to do because no disrespect for any of the positions that might be on and listening with this presentation, but sometimes changing their minds to change how they've been conducting themselves over time. Here's what we're faced with. Face with the choice between changing one's mind.

And proving that there's no need to do so, almost everyone gets busy on the proof.

And I use this at the board of directors level because people get very strong personalities about we've always done it this way. And what we've learned at summit is how do we pivot?

And I think you're gonna hear a great story from Rachel about how we pivoted from just an and I say just certified coders to certified professional risk adjustment coders. That transition has been very successful for the organization.

Go ahead.

Some of the results and, you know, Rachel is a huge contributor to this. I don't put the the details in the specific dollar amounts.

Because that's proprietary information, but you can get a view of the graph that we distribute our income earned in value based care in three buckets. And the first bucket is the one that you see on the screen today. Citizens is ten percent of the bucket. And you can see from the first year that we started in value based care, through twenty twenty two, we don't have the final numbers yet for twenty twenty three. But you can see that we've consistently moved up towards that one hundred percent compliance in citizenship.

And here's here's an example because I'd like you all to think about this All of you if you sent out a vote today and asked the physicians to vote on a new partner pick your poison. Right? How many of you would have one hundred percent of your partner's votes?

Well, in the last couple three years, and that's why it's getting closer to a hundred, we're getting between ninety six and ninety seven percent of all the partners to vote on every vote over the course of a year. And our goal, of course, is that everybody eventually will do that. Go ahead.

Here's the next compensation formula. It's about where you are in your shared savings program and what your star rating is. You can see something even back in twenty twenty four still had a high score just below four stars, and now we're approaching maintaining a five score rating in all of our quality metrics. And a lot of this has to do with what Rachel's department is doing and what they complete after the physician's already seen the patient.

Go ahead.

And then finally performance, because performance is where it all lasts at sixty percent, performance is really the the the the cost, the MER. We call it MER medical expense ratio. I know some people call it MLR, whatever your performance metric is. You can see where it's gone from twenty fourteen to twenty twenty two. Because we made a commitment to investing in a very large department in our value based care team, it's it's it's approaching eighty folks in the department, and you have to make that investment to be successful.

And Rachel's done a great job of not only adding the folks to it, but all so moving from certified coders to risk adjustment certified coders.

Go ahead.

So I'll kind of take it over there from Ed. Yes. Ed has told us the our story. I wanna actually talk about our department and, some of this is success in our department alone. But before I do that, I I just wanna make sure everyone understands when we're talking about value based care, what that means.

It is different now. The industry is moving towards value based care really putting emphasis on preventive care, making sure we're engaging our patients. And then, population health management is also a key component.

And when you think about value based care, it really is directly linking to the performance of costs quality of care and the patient's satisfaction.

So those are metrics that you must attain and that when Ed was talking about those star ratings. Those are components that, some it is gauged upon by our health plans whenever we are in con track in what we consider a value based care, contract.

So when we think about risk adjustment coding in the value based care, one of the requirements part of that citizenship model, for performance metrics on our partners is that they have to complete a risk justment coding and documentation training every year. It is a mandatory requirement.

And when I get in front of the providers. One thing I always ask them to ask themselves are are they considered in the industry a high cost, low performer, or a high quality and low cost performer. Because again, those are the components when we look in our contracts as a value based contract. Meeting those quality metrics providing great quality of care at a low cost. Next?

As we move into, a risk and HCC coding, those are the the language that we speak under our value based contracts.

Adjustment is just that process of making sure that we're reporting the full disease burden on the patient.

Once that disease burden is reported to the health plan. If it falls into an ICD ten that is classified as an HCC, a hierarchical condition category, that is then compiled into what we call a weight. We call that the risk adjustment five So certain conditions in the HCC model holds a weight and that weight that we call is called a RAS score. That is the resources in order to take care of our patients.

And generally the higher the RAS score the sicker, the patient. And, Medicare calls, the average RAS score about a one point zero.

And, talk we'll talk a little later about the new model, but, currently, a one point zero graph score is about ten thousand four hundred dollars, to take care of that patient.

Next?

So when you think about risk adjustment coding, I really throw a little extra factor in two coding, we really are auditors, because in risk adjustment coding, it's not just taken the providers diagnosis that they report the ICD ten. It's really validating that condition.

I always like to fall back on risk adjusted Solutions.

As risk adjustment coding auditors, we must make sure that the documentation is accurate and complete. And based on that documentation, we must identify the correct I CD ten code for recording In validating that condition, we must make sure that that condition that's being reported has a a status and treatment plan.

In that, we also have to make sure the highest specificity is reported on that condition.

And so what happens there is We have to know all of ICD ten guidelines.

We also have to know Medicare documentation and coding guidelines.

We then have to know coding planning guidelines.

And then we have to stay current in the industry to know what OIG is saying. What our Radv auditors are seeing and what trends and patterns are going on as as auditors outside auditors are reviewing and actually doing take backs because of inappropriate coding and documentation.

So there's a lot involved in just plain old coding and reporting for fee for service. When we when we move in fee for service world, it was how much did I do today? But when we look at value base, it's how much, not how much we did, but how well we did. And not just on the organization how well we did, but how well did the patient do? So the really identifying the patient's full disease burden and making sure that that documentation is, there.

Compliant and accurate and complete.

Challenges, of course, is that? Is that, accurate and complete documentation?

When We've transitioned providers from fee for service world into value based contracts. Again, that diagnosis status and plan is the number, number one highlight, in transitioning documentation.

Care cause it a laundry list if you just tag on conditions in the assessment area as risk adjustment auditors, we have to validate that condition by the status of it. And then what are you doing for it? And as we have seen, and I'll share with you some upcoming, movements in our world.

Our auditors, our OIG auditors, our Radby auditors are getting a little bit more, stingy on validating our our claims as well. So I, you know, I just push that needle with our providers that It's okay to say continue the man the medication that you're already taken, but I don't know what that medication is. That they're taken for whatever condition because I'm a coder. I'm an otter coding auditor. I can assume and I may even know but I don't have that right to make that determination. So we are asking providers to be more specific in their treatment plan and to really align what exactly is going on with that care.

Now if that is not done, of course, the impact is reimbursement and program performance.

Reimbursement in the fact that if we don't, provide the full disease burden of that patient, we're not getting the right RAV School the right range and the right resources to take care of that patient. And then, of course, meeting our performance metrics as well.

The compliance issue of it as well. We are responsible in value based care if you, or find yourself in a risk contract.

We are responsible for utilization of care. So if we are doing over utilization and the cost is higher than the resources that were funded for that patient. We're held accountable for that nation. So, definitely making sure everything's reported, accurate and validated, year over year is very important in our risk value based model. Next.

So, you know, talking a little bit about Summit. I'll give you some success stories, but if you think about your own organization, how you can move and transition your departments, into really, focusing on some of these value based risk adjustment contracts, definitely need trained train people that understand risk adjustment coding.

Making sure that I I we always say audits. Everyone hear audits.

We're scared of audits, so I like to always say review. So, definitely conducting reviews to make sure accurate and complete coding is occurring.

Not only on your provider's documentation, but how is your team? How are your coding?

Coders assessing the documentation or reporting? And then, of course, the benefits would be that improved coding accuracy, reducing compliance risk, and definitely optimizing reimbursement for accurate and complete patient and disease burden, making sure we have those resources to take care of the patient.

We always talk about, HCCs the rafts for the way the resources, the, to take care of the patients. But, you know, coding, if we think about where what started coding, was disease, disease burden. And so sometimes, we forget that When we're reporting certain conditions, whether there are HCCs or not, by really focusing on the full disease burden of the patients Maybe there's a, something the health plans will initiate because they notice a certain disease prevalence. And so they can do actual care studies of other resources to take care of our our patient population just to keep them healthy. Outside of always just focusing on the HCC concept.

Next.

So staff training, I think we talked about that investing in training programs.

That's something that, I'm very thankful that leadership allows me to do. We are able to do CRC boot camps and have our team that are not certified in risk adjustment. We actually highly recommend they get certified and then they are able to go through that work, shop to be successful.

Peer peer reviews. That's something we do is that we actually that's how we gauge their accuracy. We have peer to peer audits. Everyone's responsible. We're looking over each other's shoulder. And then continuous education.

Another thing that we do in our department is we have those one hour CEU opportunities.

And we actually have, some of our team leads and others that are high high quality, staffing that will develop holding material in we'll trend what kind of efforts we need to make as far as education that maybe we're not all thinking the same on or have questions on. So those, education workshops are really highly encouraged.

So when I we talk about advantages of having those certified auditors, in risk adjustment, Again, that improved accuracy.

Did a survey on my own team. You know, what do they think the value of getting certified because, that was mandated, in twenty twenty two to twenty twenty three that they get their CRC.

You know, if if you're certified, you do have there's a sense of pride of that certification and of knowing that you know the material. You was able to take that test, pass it, and it it does boost your confidence a little bit.

Ninety five percent is a national average for accuracy.

Ours is ninety seven. So our teammates have to achieve a ninety seven percent accuracy rate in our department.

And I can tell you, they hit ninety nine.

So, when you put it in their face, you gotta hit a ninety seven. They're like, I I can't do that, you know, because they're always so used to here in ninety five, but when you show them, we're at ninety nine. What are you worried about? So it's always great to be able to give that positive feedback.

Compliance assurance, you know, lots and lots of audits are going on right now. So we really wanna make sure that we're being compliant, that we're in our organization all the way down to our provider and patient care.

So we do have those peer to peer reviews in house and education program and then maximizing those resources.

Definitely utilizing AAPC.

They do have different workshops that you can attend. As a CPCI, I'm able to, conduct workshops based off the CRC curriculum.

Next.

So a little bit more about our team at Summit, there's two different teams.

That's fall under my umbrella. We have our pre visit planning coatings specialist team. And then we have our coding auditor support specialist team. Our pre visit planning team utilizes our EMR. They look through the record look for conditions that need to be assessed on that concept of an HCC year over year.

They also look at outside records.

We are able to tap into portals to see if they went anywhere at any hospital. So we always make sure those medical records are uploaded into the EMR so, the provider has those documents when the patient arrives at their appointment. We work two weeks out and we work on our risk contract health plans.

So two weeks out, we'll get their appointment scheduler and then we focus on their Medicare annual wellness visits.

We do. We are stepping into the CDPS and HHS model, the commercial and Medicaid risk model.

But it's it's it's a pilot and a pilot stage right now but it's still the same workflow.

Just looking at different conditions.

And then another thing that we added to our team was the CDI concept. So we actually have registered nurses working for our department as well under the pre visit planning.

That was a bonus.

That's always been my vision is get really get that clinical aspect into our risk adjustment coding sets. So any clinical indicators that we identify of a new diagnosis that, through disease progression alone we will prompt those to our providers as a suspected diagnosis for review.

The coding support team is the back end side. So again, we're, really just focusing on our value based risk contracts.

We focus on the annual wellness visit and, our providers are, you know, trained and and encouraged to at the annual wellness visit assess all chronic conditions at that visit. Make that the one true record.

We focus on them and so we wanna make sure that we review those as many as we can. So what they do before that claim is, submitted, they will look to see if we have that diagnosis status and plan.

If we don't, we have a good query process in place. So we will query the provider and ask for clarification.

We'll look at clinical indicators that we might see.

We'll look at many times they'll talk about conditions. Just don't drop them in the assessment. So we do a thorough review on that note, make sure it's compliant before it goes out on the claim. And then again, with that strong leadership backing, another mandatory starting this year is that providers have to answer a query.

They were pretty good at it last year.

We really started monitoring it, but this year it became a mandatory that, they have to respond to our query.

They may not have to agree with us. And we don't want them to always agree with us, but, they do have to at least acknowledge they received it. Next?

So here's our success. When we think about, value based contracts in the risk, department, risk adjustment concept, that HCC recapture is a a term that will be used by health plans. Our recapture rate is pretty good. Our, you know, we share with Humana or ACO and Blue Cross.

This is not year out outside of Humana. And another thing, we still have when you get your data from your health plan, they're always gonna be about sixty days out. They still have to have claims process.

So, And another thing in recaptureate conditions go away. So you will never see a hundred percent recaptureate. And if you do, there's something wrong.

But we like to say that we're pretty good, because some conditions just cannot be reported year over year in that still stays in the denominator.

So, that's a success for us. We do make goals for ourself and for a department as an organization.

And, we make them stretch goals. With the understanding, the buy in from the team that you know, their stretch goes. We hope to attain them.

But we and we work really hard to attain them. So pretty pretty happy that we met all our our goals as we set.

Another one was our query. As I mentioned, they were pretty good responding to us. We had an eighty seven percent response rate.

Because we was just slowly starting being more vigorous in our query rate. We set a goal at eighty five percent. So we attained that that goal.

What was also something we throughout was those suspected conditions that we queried on. We, you know, we had more, eighty six percent there just on a suspected condition that they responded back to.

Another thing that we started in twenty twenty three and because of the huge, positive response.

We're hoping to make that a mandatory thing now. Like I mentioned, we really focus on our Medicare population.

But we are venturing into our pediatric commercial world. So we did a pediatric CDPS risk adjustment training and because of that training and success of it. They they, did ask that we would make that a mandatory training as we move forward. So that's in the work for the board to approve.

So I'm kind of excited about that as our department grows. And as I mentioned, the CRC Boot Camp, we had ten employees.

That did the boot camp and they all passed. So that was a success for our our department as well.

So when we look overall, as we focus on risk adjustment, coding documentation.

Just really key takeaways. We have that annual mandatory provider training that they have to do. We have a pre visit planning workflow. We have a post visit planning review.

We have a query rate process.

Those those things are aligned with our metrics here to help us be successful.

Next, And when I talk about, we have great leadership, by end and, very huge support but it really has to go to the employee level. They have to have the buy in and they have to have the drive to do to do the metrics because they are high metrics, high standards, ninety seven is a high standard.

So I always praise about this. This is, our department statement and this was created by our team.

So we did take some time get together and as a team came up with the mission. And again, it's to strive for excellence, making sure that we're maintaining accuracy and integrity of the patient's health data. And working alongside our providers to make sure that we're getting that full complete picture of that patient's disease burden, health, and well-being. And through that, we're able to promote financial stability to summit and also have the resources to take care of our patients.

And so that was that's our mission statement. That's our drive as we review our patient's records. It it's about patient care. Next.

So some future movements in risk adjustment. I just wanted to share, probably many of you've heard the new model in CMS HCC is the version twenty eight.

We're still in that blended model of version twenty four and twenty eight. So it does make Cody world a little bit crazy. Because some of the HCCs that are in the old model is no longer in the new model, but our reviewers still have to keep it in the back of their mind that There are still HCCs that we need to make sure the providers are reporting on. Because in version twenty four, there's, as we move into version twenty eight, There's two thousand two hundred ninety four HCCs that will be removed from the model. However, today, we're still reporting those. Because, we're classified in a blended model right now. But for next year, we won't be receiving those, resource the weight, Ralph waits for those HCCs.

So that can that's a little challenging. Technology is not up to par.

Our our ICD ten has already transitioned into, not reporting the HCCs.

So, it takes a little bit of, manual work to remember, hey, you know, we still wanna look at those because we may not have our EMR flag it or our ICD ten code flag in those conditions.

But another thing that's happening in is our OIG audit. So I just wanted to share they really, really ramped up the Medicare Advantage, audits. So as you can see, last year, they generated, those high risk conditions.

That's your, stroke, your MI, your carcinoma coach or PBD.

They did that last year, and they did a lot of take backs on that. But they they're keeping that into effect.

They're also doing those health risk assessment audits.

So, those are like your Medicare Advantage wellness visits.

They're gonna start reviewing those and see if there's any inappropriate coding or documentation going on in those reviews. So that's starting next year. And then they're carrying it on into twenty twenty six where they're gonna look at the specific unsupported medical record documentation for HCCs being reported. So right now, we're in that high risk condition stage, but in twenty twenty six, it's gonna be an over overview of medical records in general as it relates to Part C.

Now I did skip over the second bullet. I don't know if there's anybody on that works for a health plan. This is gonna be your baby.

You know, Medicare is bidding on saying it's out there. We told you how to do it. You gotta find it. Well, OIG did the same thing.

They they developed the toolkit for high risk diagnosis codes. They did the mapping, and they said, here it is. And we're gonna audit you on it. So I just wanted to share that that toolkits out there, it's really designed for health plans to really do some mapping to, make sure they're monitoring those high risk diagnoses.

But it's something that we're also utilizing here at Summit to make sure our IT and our coding team is aware of what's going on. And that's the key. I you know, that's the takeaway. We have to really make sure that we're staying within, in the industry.

Staying aware of what we're doing and, where the what's going on as far as audits. And, The other thing is getting that leadership by him. And one way of doing that is just showing your worth.

Making sure that You praise when praise is due.

Learn learn where we can.

But making sure that, I always that's one thing I advocate for my team in just making sure that, the work that we're doing is actually being showed and proved proved in, just in, audit reviews that we get. As well as, just the stars. I mean, hitting a five star isn't an easy achievement, but it it does take take a village.

Next.

So, as we go in, to talking about value based. I'm gonna turn it over and let Ed talk a little bit more, about value based care and risk based based program.

Thank you, Rachel.

Glad to hear all the things that you passed along to everyone.

And I and I think that the slide you're looking at now is the end result, but you had to begin to promote the idea of having risk adjustment coders and provide evidence to the leadership team that there's an ROI.

And I'm I'm doing all three bullet points at the same time, in that you go to the board of directors and you know adding fifteen folks to your staff and eventually twenty, you know, and then again, twenty five folks working on your staff to get this accomplished.

It has been a monumental success with Rachel's team working towards becoming certified risk adjustment coders. It's paid off, and we see an ROI every time we add another body in that particular department, it enhances the return on investment for us. And I can't say enough about the job they do. But it's an easy ROI. If you sit down and calculate each individual person that you wanna add to your team, and find out how that increases the return on your fee, not your fee for service, excuse me, on the value based care payments that you're going to receive approximately eighteen months later, you watch the difference between having certified coders and risk adjustment coders, and you'll be able to provide evidence to the leadership team that there's a true ROI in behalf.

Go ahead.

I think we're in the Q and A section now.

Alright.

This was a really, really, really incredibly information packed session. So I thank you guys, Rachel, and Ad for sharing your experience and your expertise.

With that, of course, we have quite a few questions. So I will go ahead and lead us off Rachel.

It's this question is kinda part one and part two. We had a few people ask about coder productivity, with that ninety seven percent accuracy rate that you reported, what does the what is the productivity requirement or the CRC auditor to provider ratio look like for summit?

So in our pre visit planning, we just increased the as well with our accuracy.

In our pre visit planning work where anywhere from thirty to thirty five reviews.

And again, they're looking at our risk contracts, upcoming appointments two weeks out, and that's what we kinda gauge through.

In our coding support back end, so this is looking at the claim before it drops.

We are looking at seventy to seventy five claims a day.

And there is a hybrid with our department.

We we have some team members that will escalate if a query needs to be done.

And so they don't actually have to send the query, but and so those that have to actually send the query, their their, their rate goes down just a little bit. So sending the escalation without sending the query is seventy to seventy five claims a day.

Okay. And someone asked, or I had a couple of people ask about with that accuracy rate that you guys have, How is accuracies or is it based on the payer, what they agree with on the claim, or how do you go about validating, or scoring for accuracy.

It's a peer to peer review.

So their peers are reviewing and if they see that something should or should not have been reported.

That's how how they're monitored.

And so I would like to add something to that if I could. Sure. If you don't mind.

It's and it's based on Facebook's, please. Yeah.

Yeah. No. Those guys. Go ahead, Ed.

Yes. You know, Rachel doesn't always explain the success that she's had. So I like doing it for her. But for an example, we had one of our payers. You know, the names are unimportant.

That ran an audit.

And covered many, many patients.

I don't remember, Rachel. A hundred, two hundred, three hundred. How many were there?

A lot.

Yeah. There were a lot.

And they had used certified coders to do the audit.

Rachel and her team, risk adjustment coders went back and reviewed they audited the audit and kicked back ninety five, ninety six percent of them and said you're wrong.

And then we had to have a discussion that if they're gonna audit our patients, they need to have risk adjustment auditors to do it because they can't stack up for the quality that we have with the risk adjustment auditors. And we won that battle.

And to me, you know, I'd like Rachel to, you know, express that to everybody because That's a great success that her team, you know, you look at the payers. They're doing billions than billions, you know, and we're not. And we're able to provide evidence that there's a return on investment if you have this kind of caliber individual working on your team.

Absolutely. Absolutely. I wholeheartedly agree with that with that comment.

Yeah, definitely. Alright. So here's another question, Ed, I guess I'll direct this one to you. We've had a couple people ask, how do you get physicians to move away from fee for service and embrace value based or risk based contracts. How how were you guys successful? And what do you think is the secret sauce for that?

Yeah.

If there is one.

Great question, Lee. You you've heard the answer already because you were at the MGMA leadership.

Isn't that what it was? Leadership?

Was. Conference. Yes.

And I go through this. It it's a very, you know, it's an hour long demonstration about how we incentivize them financially.

So we don't have time for that, but I'll give you the high points.

We created a call it a an incentive program for physicians to readjust what they're doing when they're seeing a patient that has a risk based contract.

And it's not replacing that income piece. And I think it's very important to realize we didn't replace fee for service.

The incentives we put out are added.

It's in addition to doing fee for service. They didn't transition from fee for service to value based care. They still have the fee for service done. Our contracts in the value based care space has a component of fee for service when you see the patient and it's paid.

In addition to that, if you can, as Rachel said, if you can make sure that they go that we treat them, at a lower cost with equal to or better outcomes.

Now we're gonna do better in the value based care space. And that's in addition to the fee for service we collected.

Well, like I said, it's it's a highly complex incentive program that it took a few years for all the components of the reimbursement model to incentivize physicians to document to the highest level of specificity, to readdress all the eight ccs, all of the above. We had to put incentives in place And what that does is when the check arrives, those physicians that achieve the target that we were looking at get a bigger slice of the check that arrives.

And after the first two years, competition started rolling. You know, it's like, how do I do as well as that other physician over there? And it really helped the organization get better at what the goal is, which is equal to or better outcomes at a lower cost. And it really made a big difference.

Absolutely. Friendly competition is always a good thing regardless of industry.

Yes.

I think that your comments leads us to this next question.

Someone asked how should we go about selecting payers to work with? When it comes to these contracts.

So, you know, for me, and, you know, and I'll ask great you to follow-up afterwards, for me and the role that I play, I try to find the ones that have been willing to work alongside of us in the commercial space.

And those folks who were helping us along in the commercial space, they were the first groups that we started having discussions with and then subsequently negotiate with getting VVC contracts.

And that might not be the best way, but it worked for us. We started out with, you know, one, two, and three in the commercial side. And we moved over into the value based care space, and it wasn't in the same order, one, two, three. A couple of them responded a little more, with a little better and richer contract than maybe some of the others did. But it's a matter of sitting down and deciding who which one of the organizations truly wants to be a partner with you.

There are some, and I'm sure, you know, I won't mention names, but everyone's gonna know who I'm talking about. There's one particular payer that doesn't necessarily want to be a partner with you. And if you wanna do that, well, it's difficult. But you find some you find the groups that you build a relationship with, and you'll find out that your value based care contracts can be very achievable with your physicians.

Okay. Very good. Rachel, did you wanna add anything to that?

I, you know, on contract as as a whole that's really kinda adds thing, but when you think about in my world working with the different health plans, those that, have a high outcome, you know, when they can prove it of their success, their their metrics, you'll find that they have a team. They have an internal team that understands and speak the language as well. And so that's you know, I'm privileged to have good relationships with several of our health plans that we do, work with and having that team and and just capitalizing on whatever they can bring to the table and just supporting each other because in the end, it's about the patient.

And providing the care for the patients. So, we do we do have a good relationships with all of our risk contract plans.

Okay. That's good to know. And that's part of the reason you guys are, are so successful. All these pieces that you fully understand and and leverage, so beautifully. So very good to to hear and to see a organization thriving in this space.

I do have a question about AI, and, you know, we can't really have sessions these days without AI coming up, but some of our listeners wanna know if you use AI or any type of automation, and if you do, how is it utilized within your organization, whether that's for code selection, validation, data management, can one of you speak to that?

We're old school. Our auditors use the book. We use the book.

I know a lot of our AAPC members are smiling right now, Rachel.

There and we provide the book. Believe it or not. They actually get a book provided to them. I've interviewed people. They've not seen an ICD ten book in years and it's like, what?

So Lee, I'll ask, I'll answer that question in a macro perspective Mhmm.

That we're managing from the board of directors.

AI we know is coming.

And most independent medical groups, like summit, It's gonna be very difficult while the pricing is so out of reach unless you're one of the big systems around the country.

And we also think that it's got a higher likelihood of being attacked and we're really careful about cybersecurity.

So we're taking a very measured approach.

The first component of AI that we're using right now relates to documenting in the patient chart with the physician's assistance and having AI assist the Not diagnosing.

Just repeating and being able to work with a physician while they're documenting in the chart.

And it's gonna be a slow process for us. One, because it's a prohibitive cost to get in.

And two, I I don't think that all the AI companies that are offering this benefit yet have buttoned down the risk that exist with HIPAA compliance rules and all the other components of health care.

Good points. Those are really good points. Okay. Maybe we can take a just a few more before we, we wrap up Rachel, maybe this one is for you.

Someone wants to know about your education process for your providers. So as your auditors are reviewing the records and, validating codes, what does your query process, so your education process, looked like collaboration between the auditors and the providers.

It always helps having that backbone of the leadership that they have to answer those queries, but we follow a Hema query toolkit.

So, we stay compliant in our queries.

Through our mandatory training that we do yearly, we provide sample of documentation. We use their own work.

What we're seeing.

We also do new provider trainings quarterly So as providers join us, they are also asked to, attend that training. So We follow the trends of our organization, what we're seeing, and bring up, bring delight, things that we're seeing, but we also keep in the industry what what's out there. So we do also, educate about what OIG is looking at. So that is implemented in our, training format.

Okay.

Leah, I'll also add something that enhances the relationship between the physician and Rachel's team.

As you were talking about, you know, the compliance issues that we inserted. And every year, we learn how to pivot. One of the components that we addressed earlier.

We learned to pivot that Rachel's team is sending notices to the physicians on how to do better.

And giving them advice.

And what we uncovered when we monitored those buckets, many times they go unread, and some and even not even responded to. Right?

And we put an incentive program in how the the income will be distributed, and they have to meet a minimum threshold.

Of how when some when a certain number occurs, they no longer earn that income in that particular bucket when they've either rejected or ignored or just simply didn't respond.

So now they have an incentive and Rachel's team will feel like leadership supported them because we've redirected the physician to ensure that They're going to listen to Rachel's team, and they're gonna read it, and they're gonna respond, because it's gonna make the organization better.

And and just to yeah. And just to say the responses, I don't agree with you. That's fine. It's just give a sense.

Exactly. But it's okay to disagree. It's not okay to ignore.

Yeah. Absolutely. And that's really an education opportunity as well. Right? So as the providers are learning from the auditors as far as ways to proved a documentation, what's needed, it gives the opportunity as well for that open dialogue for the auditors also learn or gain more clinical, perspective. So I do think a response is needed, like you said, even if it's I don't agree. Just to have that further that further dial.

It is like the trending of certain queries is not working, you know, maybe that's an educational opportunity for our team. Another thing we do on education, you know, I I love this. So we have managing partners. So when they become a new managing partner, I take that on take that with w chart reviews on them.

Just just to let them know who I am, the department, making sure we connect. I have several providers once I'm on their speed dial. I love it. We do concurrent reviews.

We'll have provider call us as they're documenting. Can we get assistance on how what I need to do? What code?

So, we try to Be, I always tell our providers we're your friend. We're here to help you and we're usually a messenger.

But we try to do our best to be supportive of the providers.

Absolutely. Absolutely. Okay.

We may have time for one more question. This is around your pre visit planning.

If you have any additional details you can share about any certain programs that you use in your pre visit planning how far back do you go to review those records to identify missed opportunities when it comes to diagnoses, code reporting?

You know, that's where CDI comes into play and just having that clinical knowledge under your belt as a disease progression. So you wanna start there. You wanna make sure you're looking at lab and X-ray and think of conditions that make progress.

Because that might be when they might turn into an HCC condition.

We look at the last few notes that the provider see if he responded to sending out for any specialist treatment.

Any anything like that will follow-up. And then, of course, we have all the portals out there, the different hospitals that we can capture information.

And again, that good relationship with our health plans So our health plans have patient survey summaries.

So we have access to those patient summaries to see what last year happened to them, what was reported, things like that. So it's your lab X-ray specialist nose, hospital, and then, that good data that you can get from your health plan.

Okay.

Fabulous. And Last question and then we'll close out. Ed, maybe this one is for you pitfalls, for VBC, what happens if a contract goes negative? I don't know if you have ever experienced that, but what does that do to the incentives that you have in place if that occurs?

It in that's a great question. And Lee, you summed it up, Beth. Very fortunately, we've been doing this since twenty fourteen.

We've never had a negative result, which is good to know, but I can assure you that in our incentive program that we have for how we distribute the income?

We had planned from day one. And we've been fortunate not to have to reach into that bucket, but we already had a plan that if we had a loss and had to pay it back to the payers and CMS, we have a plan in place.

And we and we have the same plan every year about how the physicians will be sharing on that payment that goes back to the payers and CMS.

We've been fortunate. I think there's been a lot of hard work I think that we've worked diligently to be successful, and it could happen. And we have planned for it. And The physicians know what the downside risk happened to be.

Right? This is this is how much they're gonna have to carry. It's largely due to their panel side. But we do have a place and it's designed to ensure that the downside risks are being shared equally as well as the share when it's outside.

We just keep our fingers crossed and say we're not gonna have we're not ever gonna see a downside risk.

Absolutely.

That is the that is the goal. Well, thank you. Thank you, Ed. Thank you, Rachel.

Your organization is a wonderful example of, I think, how, careful consideration, strategic planning, investing really in the right resources, like our certified risk adjustment coders, and promoting, of course, positive treatment, having that, that outcome along with fair compensation for your providers. I think you guys are great examples for this. So Thank you for your expertise. Thank you for your time.

Thank you for sharing your experiences.

And for our listeners, if you wanna learn more about AAP CNR credentials, we definitely would encourage you to go to our AAPC website. Thanks again.

Thanks, everyone. We appreciate you participating. Thanks, Lee.

Yep. Thanks, everybody. And, just for a minor for those still on the call, a copy of the slide deck and a recording of this presentation will be sent out in a few days. And, there's actually a survey once we close this out. If you are in interested in learning more about the CRC certification or training, just let us know, in your web browser after this ends. Thanks again, everyone.

Thank you.

Thanks folks. Bye bye.

Have a great day, everyone. Bye bye.