You have many choices to make when it comes to how your health plan will conduct Medicare Risk Adjustment (MRA). Among the most critical choices is how you’ll retrieve your medical records for retrospective review and coding. How can you find the right partner to work with in order to ensure a successful MRA season? We recently sat down with our own medical record retrieval guru, Howard Gross, to help guide health plans in their decision-making process for pursuing medical record retrieval.
Why should a health plan even consider medical record retrieval for their commercial or Medicare risk adjustment program, given the cost?
Simply put: for the return on investment. Across our clients, we see the retrospective chart review programs yielding at least $240 per chart retrieved and coded. If you aren’t getting fully or accurately reimbursed by Medicare relative to the risk of your population, you’re losing out on a significant amount of revenue, and medical record retrieval is a vital part of securing that reimbursement.
What’s the average retrieval rate a health plan can expect?
At Verscend, we are typically able to obtain 85 percent of the total records loaded to us from a client’s chase list or our own Suspect Analytics results for MRA purposes, assuming we have an adequate timeframe. This is true of even our largest projects—the amount of records to be retrieved has no impact on our success rate.
However, every vendor has its own retrieval process, and some are obviously more successful than others. Some factors that may influence retrieval success include the vendor’s provider site-matching methodology, as well as the software used to identify sites and prioritize calls for maximum effectiveness. The level of training provided for retrieval agents is also an important factor. The better they are trained, the more success you will have.
In addition to these factors, what are some other key questions to ask when choosing a medical record retrieval vendor?
The best predictor for future success is past success. When talking with prospective vendors, ask them what percentage of records they were successfully able to retrieve on their most recent similarly sized campaigns for other health plans. What were their rates for each retrieval channel, including phone, on-site, and via electronic medical record (EMR) systems?
Not surprisingly, some vendors might skew the numbers to look as favorable as possible, so find out exactly how they calculate their retrieval rate. At Verscend, we quote our retrieval rates on the basis of the total number of records loaded, while other vendors deduct a combination of duplicate, canceled, no patient, and no record chases from the denominator in order to inflate their rates.
Ask the vendor if they place any restrictions or limitations on the total number of attempts they will make to retrieve a given record. At Verscend, we make as many attempts as necessary, while other vendors may limit theirs to a set number or long intervals, and then give up at that point.
Finally, an important question to ask your potential vendor is what percentage of their retrieval work over the past 12 months was conducted offshore. While offshore retrieval can allow a retrieval vendor to charge less, large amounts of offshore retrieval may indicate less direct attention to campaign metrics, and can result in diminished numbers of records being retrieved. Some vendors have less control over the retrieval and training processes when it’s outsourced to an overseas third party, and the provider abrasion it can cause due to cultural and accent variances can be extensive. This can lead to lower retrieval rates and strained relationships with your providers. Ask your vendor what they do to minimize provider abrasion.
What are the best practices to implement when working with a retrieval vendor in order to maximize success?
Typically, MRA season runs from the second half of May through mid-January. It’s critical that you give your vendor adequate time to complete the project. We’ve found that we achieve optimal success when that timeframe is 28 to 32 weeks. Also, make sure you build in a sufficient amount of time for the back-end processes that must take place before retrieval starts. It doesn’t happen the second your vendor has the chase list in their hands. We provide pre-launch access coordination for significant EMR sites with our clients in order to increase retrieval penetration.
As you mentioned, having well-trained retrieval agents is a critical component of a successful retrieval process. How are Verscend’s retrieval agents trained?
Verscend provides four full weeks of full-time, hands-on training for our retrieval agents before they begin retrieving records for our clients, which we believe is one of the most extensive training processes in the industry. During these four weeks, new agents undergo classwork, followed by a period of coaching with a dedicated coach-instructor with a low trainee-to-coach ratio, teaming up the new agent with the coach to observe and shadow. This phase ends with the coach observing the new agent as he or she begins live record retrieval calls. We provide feedback and coaching to the new agent to ensure success.
We also provide ongoing certification training throughout the year. Every retrieval agent is required to log into our online training system to view training presentations, which are followed by online tests to certify that the agent has reviewed and passed the training course.
Learn more about Verscend’s success strategies in retrieving medical records for our clients by downloading our Medical Record Retrieval fact sheet.
About the author:
As vice president of retrieval operations at Verscend, Howard Gross is responsible for a team of more than 500 specialists who do provider outreach and coordination to retrieve and process millions of medical records annually for Verscend’s clients. He has more than 25 years of experience in both communications and systems, building and optimizing operations for organizations that provide outreach and medical services to clients around the world.