Mar 20 2014 | Thought Leadership | By

Guest Blog: Success Managing Risk and Revenue with Prospective Health Assessments

As the October 1, 2014 date for the conversion of the medical coding system from ICD-9 to ICD-10 grows closer, pressure is increasing for coders and physicians to quickly understand, implement and use the system. This transition is especially difficult as coding grows more complicated in a nation where, according to a Partnership for Solutions report, 48 percent of the population currently has one or more chronic conditions. In addition, in the past, only Medicare Advantage and some Medicaid programs received risk-adjusted reimbursement for their populations from the Centers for Medicare and Medicaid Services (CMS). Now, in the Health Insurance Marketplace, private health plans are participating in risk adjustment as one of the premium stabilization programs—making the coding of chronic and high-risk health conditions more vital to the success of health care organizations than ever before. With all of this emphasis on correctly coding conditions for optimal revenue, programs that manage risk and revenue by increasing documentation and coding accuracy are essential. Lumeris’ Enhanced Encounter® is one of those programs designed to help payers work collaboratively with providers and practices to ensure appropriate revenues that support patient care. By engaging primary care physicians (PCPs) and their care teams, payers can optimize revenue by providing incentives, tools and resources that help care teams discover, treat, document, and code high-risk conditions and more effectively manage their patient population.

Benefits to the Practice

Conducting prospective health assessments, or Enhanced Encounters, helps practices ensure patient care compliance, improve clinical quality metrics and achieve better health outcomes for patients. It also helps practices manage patient care for appropriate and predictable risk-adjusted revenue for the payer that may then be reinvested in the practice to appropriately treat identified chronic conditions. The stratification logic, based on consideration of conditions not currently coded, diagnosis suggested by laboratory and prescription values, codes that may be incomplete, and additional care considerations including access to care issues and gaps in care, help identify patients who may have opportunities to improve documentation, coding, and/or coordination of care and who could benefit from an Enhanced Encounter. A patient-specific prospective health assessment can then be created to guide the physician in conducting a comprehensive visit with the patient that encourages screening, diagnosis and treatment and also promotes early detection of high risk conditions. These clinical encounters provide a mechanism to capture all relevant data that enhances care coordination efforts and closes gaps in care.

Enhanced Encounter as Part of Daily Workflow

At the core of the program is the enhanced patient encounter where the physician assesses a patient’s health status. Preparing for and conducting the assessment should become a part of the care team and providers’ daily workflow by doing the following:

  • Accessing a list of patients in the program
  • Scheduling Enhanced Encounter visits
  • Preparing for visits (print forms etc.)
  • Executing visits (leverage patient information)
  • Submitting claims
  • Returning Enhanced Encounter forms
  • Including Enhanced Encounter forms in medical record
  • Reviewing/responding to coder feedback

Lumeris has developed programs to educate and train providers and their office staff on completing a prospective health assessment and accurate documentation and coding which is critical to the success of the program and higher-than-average completion rates (when compared to vendor averages). Thus, providers using the Enhanced Encounter have that higher completion rate, as evidenced below.

Benefits to the Payer

The Enhanced Encounter program provides opportunities to identify new and protected revenue through the accurate coding of chronic and high-risk conditions delivering appropriate and predictable risk-adjusted revenue. This can be reinvested in the payer or their provider network. Offering incentives, tools and information to PCPs allows them to stratify their population and high-risk patients in order to identify those necessary for an Enhanced Encounter. When providers complete the assessments, it keeps the PCP at the center of health care allowing physicians to devote additional time to highest risk members, resulting in better clinical and financial outcomes as well as an enhanced patient experience. Mutual benefits brought about by the Enhanced Encounter program, along with greater collaboration between payers and providers, is essential for those health care delivery systems who want to thrive in today’s changing health care environment.

Results of Prospectively Managing Risk and Revenue

In a recent case study completed by Lumeris, a loosely affiliated Independent Practice Association (IPA) with an upside-only contract implemented the Enhanced Encounter program. Using the Accountable Delivery System Platform (ADSP)® and Enhanced Encounter logic to stratify high-risk patients, 40 percent of the IPA’s patient population was identified for the program. The completion rate of the Enhanced Encounter by participating PCPs was 68 percent, or 439 completed prospective health assessments. This completion percentage is significantly higher than the market average of 30 percent when a similar assessment is attempted by a third-party. The financial impact to the IPA was significant. They experienced a $2,500 return per completed form, or roughly $1.1 million of new and protected revenue for participating in the program in 2013. In addition to financial results, the IPA saw 95 percent of their patients annually; leading to a higher-than-market percentage in multiple HEDIS measures and is one of the top performing groups in a 40,000 member MA plan.


In our experience, the real success of the Enhanced Encounter program is in keeping PCPs at the center of health care because they are best suited to complete an Enhanced Encounter and spend the time with their high-risk patients. When payers provide PCPs with proper incentives, information and tools, they can stratify their high-risk patients, reach out to them, complete prospective health assessments, close gaps in care, improve care quality, and impact revenue through accurate documentation and coding. The Enhanced Encounter program is a proven first step for payers to collaborate with providers and care teams on their journey to value-based care. Providers and payers can work together through the Enhanced Encounter program to achieve the goals of the Triple Aim Plus One: better health outcomes, lower costs, and improved patient plus physician satisfaction.

Read the Lumeris Enhanced Encounter Point of View today.

About the Author

Terri Bellmore is an established executive with more than 20 years of experience in health care and a proven record for developing forward-thinking solutions to key health industry challenges and achieving strong market, financial and clinical results. Skilled in strategic positioning with both emerging and expanding organizations, client engagement, operational leadership, profit and loss management, and sales and network performance, Terri provides subject matter expertise and transformational consulting services as part of the Lumeris Strategic Consulting and Clinical Solutions team. Before joining Lumeris, Terri was a vice president with Universal American (UAM) where she focused on general management and oversight of Medicare Advantage markets, Medicaid/dual initiatives and accountable care partnerships. She also served as market lead for Collaborative Health Systems (a UAM subsidiary) in the development and implementation of the Maine Community Accountable Care Organization. Prior to this, Terri spent 13 years with Harvard Pilgrim Health Care, leading network and business development in the Northern New England region.

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