Risk Adjustment Overview

In a value-based healthcare system, an increasing portion of an organization's revenue is tied to how effectively they can identify and control their costs of care. It is critical to surface diagnosis gaps and address them appropriately to ensure full compensation from payers.

Currently, the Patient Risk dashboard displays patient risk gaps during the point-of-care workflow as an expanded view in the patient’s problem list. The Patient Risk section lists the patient’s diagnoses, including those from the patient’s claim history as well as those suggested by HCC coders and members of the billing staff based on chart audits, when applicable.

Since the Spring 2022 release, athenahealth partners, including payers, began to publish potential third-party external risk gaps into athenaNet, that is, add diagnosis gaps to the Patient Risk section. An added diagnosis appears like other diagnoses for the patient, but the Sources field indicates the origin of the suggested diagnosis. 

Core steps involved:

  1. Support an API interface to accept potential /suspected Gaps from 3rd party
  2. Dedupe & reconcile the diagnoses for Patient and persist in athenanet
  3. Surface the Gaps in Patient Risk tab and allow Providers to address the gap in encounter workflow.
  4. Provider action and feedback support

The initial version of this feature supported publishing a potential (clinically verified) diagnosis. Now, it also includes suspected (clinically inferred) diagnoses.

athenahealth Patient Risk Workflow

The diagram below illustrates the patient risk condition workflow in athenaNet where:

  • Potential Diagnosis is the condition manually added by HCC coders or billing staff during risk adjustment chart prep/reviews or received from a third-party source. In addition, any prior patient diagnosis condition based on claims documented in athenaNet in the last three calendar years, but not addressed in the current calendar year by the provider are classified as potential diagnosis gaps that need to be addressed by providers. 
  • Suspected diagnosis is one the provider determines a patient may or may not have based on (but not limited to) existing evidence, such as lab, screening, or prescription data. For example, a patient with a prescription for an inhaler may have asthma.
  • Dismissed Diagnosis is one that the provider dismissed since it is not clinically relevant to the patient.
  • Completed Diagnosis (risk adjustment factor) is a diagnosis state when the diagnosis is addressed in an encounter and a claim is generated in the current calendar year. Any completed diagnosis in the previous year resurfaces as a potential diagnosis for re-diagnosis at the start of the new calendar year (Jan 1st).

Image showing the workflow for risk adjustment

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