Without a doubt, risk adjusted payments are geared to primary care providers (PCPs) and form the basis of Medicare Advantage plan payments and usually those of PCPs, whether directly (as in funding) or via surpluses or bonus payments. The same isn’t true for specialists.
But specialty providers play a hugely important role in healthcare (obviously) and for the PCPs paid under this methodology. In some cases, PCPs rely on consultation notes from a specialty visit to identify and thereafter report a risk adjusted condition. Say, for example, the patient whose routine labs reveal findings that signal one of several possible rheumatological conditions. The PCP may refer the patient for a rheum consult and ask the specialist to confirm a diagnosis. In that case, the PCP would report ICD-10-CM codes for the patient’s symptoms or abnormal labs and wait for the rheum to provide the code for the exact condition after a proper work-up. The rheum’s visit note will help the PCP to assess, monitor and coordinate treatment for the condition on an ongoing basis.
For this reason, PCP offices must have an effective system for timely follow up of consultation notes from specialists who have seen their patients. Instead, many offices wait until the patient returns to the PCP to obtain any consult notes (we call this “the mad scramble”) or they “hold hostage” the referral for a follow-up specialty visit until the note from the prior visit is received. This becomes a game of catch-up and can result in delays in care or member complaints to the plan for referral issues.
In Part 2 of this blog, we will review the MRA value of specialists’ notes that contain proper assessment and documentation of the patient’s conditions.