Act 6: Quality, Risk Adjustment and Prior Authorization Assessment Guide

Evaluate Current Workflow Fragmentation Across Quality, Risk, and Prior Authorization

In last week's video, Dr. Matthew Burton took us through a complex chronic patient care journey that integrated three siloed healthcare processes: quality measurement, risk adjustment and prior authorization. Unifying these three processes at the point of care embeds precision best practices directly into the patient encounter. This drastically and positively impacts the economics, efficiency, and delivery of high-value care. 

To demonstrate the full impact of unifying these workflows, it is crucial to first establish a baseline of your current costs, efficiency, and resource allocation. Use this list of questions to enable your currently separate Quality, Risk, and Prior Authorization teams to self-evaluate their processes.

Quality Measurement 

• How do Providers currently access Payer data for Quality Measurement:

a) via an existing portal,

b) integration with SMART on FHIR,

c) Data flows directly to Providers,

d) a hybrid model?

• How many hours per week do your clinical staff or care managers dedicate to manual chart chasing and coordination between payer and provider organizations to confirm best practice compliance?

•  What is the average time delay, and estimated resource cost of the current quality cycle (claims data analysis, nurse manager outreach, follow-up appointment etc.) to close a clinical care gap for populations with chronic conditions? 
•  Does your current quality program focus primarily on broad measures (like HEDIS®/Stars) or does it have the precision to proactively identify and mitigate risk for high-risk patients before a separate chart review is needed? 
  
  

Risk Adjustment

• How do Providers currently access Payer data for Risk Adjustment:

a) via an existing portal,

b) integration with SMART on FHIR,

c) Data flows directly to Providers,

d) a hybrid model?

• What is your organization's estimated loss in revenue due to incomplete or inaccurate documentation and coding?
• What is the labor cost involved in retrospective documentation and coding processes (chart reviews, audits, and feedback) to confirm accurate risk submission?
• What is the time delay between a clinical encounter and the final submission of correctly coded documentation that ensures maximum reimbursement accuracy? 
  
  

Prior Authorization

• How do Providers currently access Payer data for Prior Authorization:

a) via an existing portal,

b) integration with SMART on FHIR,

c) Data flows directly to Providers,

d) a hybrid model?

• What percentage of additional administrative work (faxing, filling out forms, manual inquiries, follow-ups etc.) is introduced by your current prior authorization process for both Provider and Payer teams?
• What is the ongoing vendor cost of utilizing separate proprietary tools and resources for prior authorization, quality and risk programs, when the underlying patient data could be sourced from the same validated repository?
• What is the average delay a patient experiences from the time a service is ordered, to the moment the final prior authorization adjudication is received?
  
  

The technology now exists to eliminate the high‑cost of data and process fragmentation that healthcare delivery has experienced for decades. Care and code correctly the first time with Smile to unify data and processes, eliminating re‑work and silos across Quality, Risk, and Prior Authorization.