Natural language processing creates an audit trail for risk adjustment

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The best way for insurers to make sure they're in compliance with the mandates of risk adjustment is to use natural language processing for accurate documentation and auditing, according to Dr. Calum Yacoubian, director of Healthcare Strategy for Linguamatics, an IQVIA company that offers an NLP-based AI platform.

Last week's publication of the final rule for risk adjustment data validation (RADV) comes after increasingly high profile instances of apparent over coding from Medicare Advantage Organizations, Yacoubian said.

There must be an audit trail, he said. 

NLP identifies gaps in care from unstructured notes in the clinical record. It enables the creation of a longitudinal patient record from multiple providers.

WHY THIS MATTERS

In value-based care arrangements, payers need accurate risk adjustment to ensure they are properly compensated for assuming greater financial risk for patients. These savings are shared with providers.

When payers don't capture the full spectrum of a patient's diagnosis, they may be at risk for cost overruns associated with treating those unidentified conditions.

"There is a huge amount of medical record review for risk adjustment, to look at missed diagnoses," Yacoubian said.

The coding must be correct, as payment amounts are determined by risk scores associated with various Hierarchical Condition Categories or groups of medical codes linked to specific clinical diagnoses.

"As the population continues to age, the Medicare Advantage population, and therefore burden of care, is also increasing – and only set to get larger," Yacoubian said. "For the payers who are claiming appropriately, these new rules pose an increased burden upon them to ensure their submissions are audit proof."

NLP can also be used for other predictive risk modeling, such as identifying patients at risk for hospital admission or readmission, he said.

NLP has gone from something relatively niche and researched-focused to its being used by more than 50% of healthcare organizations in the United States, Yacoubian said.

THE LARGER TREND

On January 30, the Centers for Medicare and Medicaid Services finalized risk adjustment policies in a final rule to prevent overpayments to Medicare Advantage Organizations.

The Medicare Advantage Risk Adjustment Data Validation program is CMS's primary audit and oversight tool of MAO program payments. 

As required by law, CMS' payments to MAOs are adjusted based on the health status of enrollees, as determined through medical diagnoses. 

Studies and audits done separately by CMS and the Health and Human Services Office of Inspector General have shown that Medicare Advantage enrollees' medical records do not always support the diagnoses reported by MAOs, which leads to billions of dollars in overpayments to plans and increased costs to the Medicare program as well as taxpayers, CMS said.

The Risk Adjustment Data Validation final rule holds insurers accountable.

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org