In today’s fast-paced healthcare environment, efficiency and accuracy in managing patient data is paramount for both providers and payers. During the recent webinar, Streamlining HCC workflows: Enabling providers to simplify risk adjustment and value-based care, IMO Health experts addressed challenges providers face with risk adjustment management, highlighting the importance of leveraging the problem list for accurate HCC (Hierarchical Condition Category) coding.
The discussion showcased how IMO Health’s problem list tooling can notify clinicians of potentially missing HCC details based on prior encounter data, patient notes, or targeted information from payers. This in turn enhances problem list accuracy and comprehensiveness needed for CMS reimbursement for both payers and providers, and reduces documentation rework.
Pressed for time? Continue scrolling for key takeaways.
Tackling challenges in risk adjustment with the medical problem list
The medical problem list should act as an executive summary of key patient issues, yet it frequently falls short. Many clinicians face not only an abundance of duplicate, redundant, or lapsed problems but also gaps in HCC and ICD-10-CM coding, impeding patient care and accurate reimbursement.
David Green, Senior Manager of Payers Business Development at IMO Health, highlighted the difficulties in the current risk adjustment landscape, emphasizing the need to improve the management of patient problem lists in EHRs (electronic health records). Medical problem lists, he explained, often lack comprehensiveness and specificity, leading to gaps in care for patients with chronic conditions, denied claims, and increased workloads.
“Increased document specificity is a key component of addressing unoptimized and inadequately documented data, which significantly impacts workflows for risk adjustment programs,” Green said. “This includes capturing secondary codes. Without specified diagnoses, secondary code capture becomes impossible.”
Green also noted that by addressing these specificity gaps, along with fostering greater collaboration with payers, providers could improve problem lists, helping to reduce CMS audit risks and streamline risk adjustment, HEDIS, and STAR workflows.
Ensuring audit readiness in risk adjustment
Navigating HCC models is essential for accurate risk adjustment in CMS programs. June Bronnert, MHI, RHIA, VP of Global Clinical Services at IMO Health, noted Medicare Advantage’s growth to over 34 million enrollees, with CMS paying $400 billion, representing 45% of Medicare payments in 2022.
“You can see the importance of documenting all the appropriate information, especially diagnoses, to reflect the individual’s health status to ensure accurate reimbursement over the years,” Bronnert noted. “And just as with other CMS reimbursement plans, there is regulatory oversight built into the system.”
Regulatory audits, like Risk Adjustment Data Validation (RADV), confirm the accuracy of HCC coding to identify overpayments and ensure compliance. Following MEAT guidelines—Monitor, Evaluate, Address, and Treat—is critical for reducing data errors. Regular documentation reviews help providers prepare for audits and maintain compliance in the evolving Medicare Advantage landscape.
The power of specificity in the medical problem list for risk adjustment
Bronnert discussed how the problem list can help ensure every diagnosis is captured with the needed specificity for accurate patient profiles. IMO Health problem list tooling is built on clinically vetted, meticulously maintained terminology to ensure compliance with regulatory standards.
“A problem list is like the table of contents for the record,” Bronnert said, “and accurate, up-to-date information also facilitates a shared location of information amongst all providers… supporting the risk adjustment model to ensure that the most specific data is documented to reflect an enrollee’s health status.”
With IMO Health problem list solutions, providers have achieved higher RAF scores, streamlined workflows, and enhanced audit readiness.
One step higher: Adding payers’ data layer to the problem list
To help organizations achieve the level of specificity in EHRs required for risk adjustment and value-based care, IMO Health can also integrate payer-sourced data, such as claims and clinical reviews. Wes Galbo, SVP of Product Management at IMO Health, underscored how claims data can be seamlessly incorporated into clinicians’ problem lists, enhancing patient care and maximizing reimbursement. This integration helps identify appropriate encounters for interventions, ensuring physicians receive actionable, evidence-backed recommendations before patient visits.
This approach streamlines payer-provider collaboration by embedding risk adjustment suggestions directly into problem list workflows, improving documentation accuracy and supporting audit readiness.
“At the heart of everything IMO Health does, of course, is driving specificity,” said Galbo. “We recognize it’s not sufficient in today’s world for a physician to simply record diabetes. It requires additional levels of specificity regarding things like long-term insulin use or complications.”
By guiding providers through detailed documentation steps, IMO Health ensures diagnosis specificity in the medical problem list that optimizes care and reimbursement.
