In healthcare, especially value-based health plans, quality is paramount.

And that requires a cooperative effort on the part of health plans, providers, and members. However, it is ultimately the responsibility of the health plan to ensure that quality measures are being met. This requires a large allocation of resources and staff to ensure that efforts are properly documented and coded, and to provide the necessary education to providers and their staff to meet standards.

Health plans can increase their membership though direct enrollment and expanding their provider networks, but this generally would require a proportionate increase in staff and resources to maintain quality.

However, what if quality compliance could be made more efficient, and staff more productive? In many health plans, there is a lot of effort placed on getting documentation from providers, and it may come in many different formats. Some submit by portals, other email, others fax, others have to have a provider rep come into their office and physically scan the documents themselves.

Then, those documents and the data all have to be re-entered into internal review and reporting systems. That is a time and labor-intensive process. What if that effort was placed elsewhere?

Looking back at the 2019 reporting year, one of our clients was able to increase primary care providers’ compliant documentation of HEDIS measures by 30% and risk adjustment by 41%, without any additional staff in those departments.

What changed? They simplified the reporting workflows and were able to reduce their internal review and feedback times by 81%. This gave their staff more time to focus on education and direct provider engagement, and in several cases have providers re-submit documentation multiple times to get it right.

We did a roundtable webinar with one of their quality mangers discussing their strategy and at the end he spoke about how their plans sees a path to increase membership by even as much as 5X, without having to 5X their internal staff.

If you’d like to see their case study, or hear the roundtable, reach out and we’ll send you the links.

Together, we can continue increasing the quality of health care for everyone, and do it in a cost-effective manner.

Stay well!

-John