Natural Language Processing creates an audit trail for risk adjustment

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According to Dr. Calum Yacoubian, director of Healthcare Strategy, Linguamatics, an IQVIA company, the best way for insurers to make sure they are meeting risk management mandates is to use natural language processing for accurate documentation and auditing. artificial intelligence platform based on NLP.

The release last week of the final risk-adjusted data verification (RADV) rule came after increasingly high-profile cases of apparent over-coding by Medicare Advantage organizations, Yacoubian said.

According to him, there should be an audit.

NLP identifies gaps in treatment through unstructured notes in the medical history. This allows you to create longitudinal patient records from multiple providers.

WHY IS IT IMPORTANT

In cost-based care arrangements, payers need precise risk adjustments to ensure they are adequately compensated for taking on more financial risk for patients. These savings are shared with suppliers.

When payers do not cover the full spectrum of a patient’s diagnoses, they may be at risk of cost overruns associated with the treatment of these unspecified conditions.

“There is a huge amount of risk-adjustment medical records to look at missed diagnoses,” Yacoubian said.

The coding must be correct, as the payout amounts are determined by risk scores associated with different hierarchical categories of conditions or groups of medical codes associated with specific clinical diagnoses.

“As the population continues to age, the number of Medicare Advantage enrollees, and therefore the burden of caring for them, is also increasing—and will only increase,” Yacoubian said. them to make sure that their materials are confirmed by the audit.
NLP can also be used to model other predictive risks, such as identifying patients at risk of hospitalization or readmission, he says.

According to Yakubian, NLP has gone from being something relatively niche and research based to over 50% of healthcare organizations in the United States.

BIG TREND

On January 30, the Centers for Medicare and Medicaid Services completed a risk adjustment policy in the final rule to prevent overpayments to Medicare Advantage organizations.

The Medicare Advantage Risk Adjustment Data Validation Program is CMS’ primary tool for auditing and overseeing MAO payments.

As required by law, CMS payments to MAOs are adjusted based on members’ medical conditions, which are determined based on medical diagnoses.

Studies and audits conducted separately by CMS and the Office of the Inspector General of Health and Human Services have shown that the medical records of Medicare Advantage members do not always support the diagnoses reported by the MAO, resulting in billions of dollars in plan overpayments and increased treatment costs. the Medicare program, as well as taxpayers, CMS said in a statement.

The final risk-adjusted data validation rule puts the responsibility on insurers.

Twitter: @SusanJMorse
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texasstandard.news contributed to this report.

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