Protecting Your MSSP Benchmark: Why Accurate Risk Capture Every 90 Days Matters
MSSP success is earned in the details, small, overlooked clinical details that build your risk score and, ultimately, protect your benchmark. If you’re leading a medical practice or managing an ACO, there’s one golden rule to remember: accurate risk capture isn’t just documentation; it’s your financial defense. And it starts with a repeatable, 90-day workflow to flag, document, and close suspected conditions.
We’re going to tell you how accurate risk capture safeguards your benchmark in the Medicare Shared Savings Program, why 90-day cycles matter, and what you can do today to get your team aligned and compliant. Let’s break it down.
Understanding the MSSP Benchmark and Why It’s Vulnerable
Your MSSP benchmark is the financial baseline CMS uses to measure your ACO’s cost performance. It accounts for your beneficiaries’ historical spending and their expected future costs based on risk scores. The more accurately you document your patient population's disease burden, the more precisely CMS can set your benchmark.
If conditions aren’t captured in time, or worse, missed entirely, your benchmark will be artificially low. That sounds good in theory (“lower benchmark means easier to save money,” right?), but in reality, it sets you up for failure. Why? Because your patient population’s true complexity isn’t reflected, which means your actual spend could exceed an under-calibrated benchmark, making it harder to generate shared savings or avoid losses.
Risk Adjustment and the Role of HCC Coding
CMS uses Hierarchical Condition Categories (HCCs) to assign risk scores to Medicare patients. Every chronic condition, from congestive heart failure to diabetes, adds to a patient’s overall risk profile. However, here’s the catch: these conditions must be re-documented and re-evaluated annually.
If your ACO fails to capture and recapture HCCs annually, or worse, across 90-day care intervals, your patients’ risk scores regress, and so does your benchmark protection. That's where many ACOs falter: they rely solely on annual wellness visits, instead of incorporating condition capture into the daily operations of the practice.
The Case for a 90-Day Workflow
At Chirpy Bird Inc., we recommend a 90-day rhythm for identifying and closing care and documentation gaps. Why 90 days? Implementing quarterly risk capture every 90 days is crucial for maintaining and protecting your MSSP benchmark. This schedule aligns with established protocols for managing chronic conditions, enabling consistent monitoring and intervention. Regularly assessing and updating risk profiles guarantees that emerging or suspected conditions are identified and addressed promptly, avoiding potential delays in treatment and care management. This proactive strategy is essential for success. By staying ahead of developing health concerns through consistent risk capture, healthcare providers transition from a reactive to a preemptive approach. Let’s break it down:
Flag: Every 90 days, clinical staff should flag patients with potential risk conditions not currently captured. This may come from billing history, clinical algorithms, or care management notes.
Document. During the patient encounter, providers should confirm and document conditions using the proper ICD-10-CM codes tied to HCCs. EHR prompts can support this step.
Close: Finally, the suspected condition is either confirmed and coded, ruled out, or referred for further evaluation. Closing the loop is key, open conditions are red flags during audits and offer no protection to your benchmark.
This 90-day cycle ensures you aren’t leaving risk adjustment dollars and data on the table.
What Happens When You Skip the Cycle?
Let’s say you have a 72-year-old beneficiary with poorly controlled diabetes, but that condition wasn’t re-documented this year. That means CMS doesn’t apply the associated risk adjustment factor. Your benchmark is now under-weighted by thousands of dollars. If this patient ends up hospitalized, your cost performance will take a hit, without the buffer of appropriate risk adjustment.
Now multiply that by 100 patients. The financial risk to your ACO becomes unsustainable.
Worse still, if an audit reveals chronic conditions were treated but not coded, or suspected but never addressed, your organization may face compliance penalties or clawbacks.
Effective Strategies for Maximizing Results
Let’s move from theory to action. Here’s how you can build an effective 90-day suspected condition workflow into your MSSP strategy:
1. Build a Centralized Suspect Condition Registry
Create or purchase a registry that tracks patients with suspected conditions based on billing history, medication use, and care gaps. For accurate MSSP benchmark protection, practices should establish a registry to monitor patients with potential conditions that may require specialized care. This registry can be built or acquired, and should identify patients based on billing records, prescription data, and gaps in care. It is essential to capture and update this risk information every 90 days. This registry should be reviewed quarterly and shared with care teams before patient visits.
Look for risk capture tools that integrate with your Electronic Health Record (EHR) and enable seamless reporting to the Centers for Medicare & Medicaid Services (CMS) through your Accountable Care Organization (ACO).
2. Train Providers on Clinical Validation
Clinicians must understand that coding isn’t clerical, it’s clinical. Set up quarterly training sessions to review high-value HCC codes, suspected condition workflows, and documentation dos and don’ts.
Use real patient scenarios to teach pattern recognition and reinforce the link between coding and reimbursement.
3. Integrate Risk Capture Into Pre-Visit Planning
Make it standard practice to review suspected conditions during pre-visit planning. Nurses, medical assistants, and care coordinators should flag any suspect diagnoses for review during the visit.
This can range from a simple dashboard in the EHR to a complex AI-supported clinical decision support tool.
4. Leverage Clinical Decision Support Tools
Many ACOs are investing in technology that can help identify coding opportunities in real time. Clinical decision support (CDS) tools can review a patient’s chart and suggest likely high-risk conditions (HCCs) based on laboratory results, medications, and medical history.
Ensure that any tool used meets HIPAA compliance standards and supports manual clinician overrides.
5. Conduct Monthly Chart Reviews
Don’t wait until the end of the year to discover missed risk adjustment opportunities. Assign staff to audit a sample of charts monthly, focusing on patients with high utilization or suspected condition flags.
Then, use that data to adjust workflows, improve provider training, or refine your list of suspected conditions.
6. Engage Patients in Chronic Condition Management
Accurate risk capture also depends on accurate history and consistent follow-up. Educate patients about the importance of keeping regularly scheduled follow-up appointments. Emphasize to patients the necessity of consistent follow-up appointments for chronic conditions. Schedule routine visits in alignment with the 90-day cycle and incentivize patients to return for care.
Simple outreach, such as SMS reminders or portal messages, can dramatically improve show rates and documentation closure.
Compliance Counts: The Risk of Inaction
CMS takes risk score accuracy seriously. Over-coding or failure to validate HCCs can trigger audits, revenue clawbacks, or even fraud investigations. That’s why it’s vital to document to the highest level of specificity and close every suspected condition either through confirmation or clinical evaluation.
Chirpy Bird Inc. collaborates with practices and Accountable Care Organizations (ACOs) to implement compliant risk capture workflows that withstand audit scrutiny. We help clients avoid penalties, improve their HCC coding accuracy by over 20%, and protect their MSSP benchmarks through evidence-based strategies.
Closing the Loop: Benchmark Protection is a Team Sport
Accurate risk capture isn’t just an EHR function or a billing task; it’s a team effort. Providers, coders, nurses, care coordinators, and even front desk staff must understand their role in protecting your MSSP benchmark.
And it doesn’t have to be overwhelming. With a simple, repeatable 90-day process, you can take control of your risk adjustment strategy, avoid costly surprises, and position your ACO or practice for long-term success in shared savings.
Your Next Step
To maintain your MSSP benchmark, no single solution exists. Success hinges on consistent, quarterly execution. Accurately identify eligible patients and meticulously document their information. Protecting Your MSSP Benchmark: A Comprehensive Guide to Accurate Risk Capture
Maintaining your Medicare Shared Savings Program (MSSP) benchmark is not achieved through a single, quick fix or a one-time implementation. It requires sustained dedication and a strategic, ongoing approach. Success in this crucial area hinges on the consistent, quarterly execution of a meticulously designed process. At the heart of this process lies the accurate identification of eligible patients, accompanied by the documentation of their health conditions and associated risk factors. Achieving success in this area requires a well-structured and consistently applied quarterly procedure, primarily focused on accurately identifying qualified patients and thoroughly documenting their medical conditions and associated risk factors.
This is not a task to be taken lightly. The accuracy and thoroughness of risk capture, conducted every 90 days, directly impact your benchmark and, consequently, your financial success within the MSSP. To ensure you are on the right track, it's imperative to establish clear protocols and invest in robust systems that support your quarterly efforts.
Here's a breakdown of what this entails:
1. Accurate Identification of Eligible Patients:
Data Analytics: Leverage advanced data analytics tools to identify patients within your assigned population who qualify for risk adjustment. This involves analyzing claims data, electronic health records (EHRs), and other relevant sources to pinpoint potential high-risk individuals.
Regular Audits: Conduct regular audits of your patient roster to verify eligibility and ensure accurate attribution. Changes in patient demographics or healthcare coverage can impact eligibility, necessitating ongoing validation to ensure accuracy.
Collaboration with Providers: Foster strong communication and collaboration with your network of providers. They play a vital role in identifying patients with complex health needs and documenting their conditions thoroughly. Utilize sophisticated data analytics platforms to ascertain patients within the designated population who meet the criteria for risk adjustment. This entails examining claims data, electronic health records, and other relevant data sources to identify individuals with potentially elevated risk profiles precisely.
Conduct systematic audits of the patient roster to confirm eligibility and ensure precision in attribution. Fluctuations in patient demographics or healthcare coverage may influence eligibility, thus necessitating continuous verification procedures.
Cultivate robust communication and collaborative partnerships with the provider network. Providers are instrumental in identifying patients with intricate health requirements and in the meticulous documentation of their respective conditions.
Fluctuations in patient demographics or healthcare coverage may influence eligibility, necessitating ongoing verification procedures.
Seek out robust communication and collaborative partnerships with the provider network. Providers play a crucial role in identifying patients with complex health needs and in meticulously documenting their respective conditions.
2. Meticulous Documentation of Health Conditions:
Detailed Clinical Records: Ensure that providers document all relevant diagnoses, treatments, and services with a high level of detail. Clear and comprehensive clinical records are essential for accurate risk adjustment coding.
Coding Expertise: Invest in coding expertise or provide ongoing training to your staff on the latest ICD-10 coding guidelines. This ensures consistency and accuracy in assigning diagnosis codes.
Hierarchical Condition Categories (HCCs): Pay close attention to Hierarchical Condition Categories (HCCs), which are used by CMS to adjust payments for risk. Ensure all relevant HCCs are captured and documented appropriately.
3. The Importance of Quarterly Execution:
Consistent Workflow: Develop a standardized workflow for your quarterly risk capture process. This includes defining roles and responsibilities, establishing timelines, and implementing quality checks at each stage of the process.
Technology Integration: Utilize technology to streamline the risk capture process. This may involve integrating your EHR with risk adjustment software or implementing data dashboards to track progress.
Continuous Improvement: Regularly review and refine your risk capture process based on performance data and feedback from your team. Identify areas for improvement and implement necessary changes to enhance accuracy and efficiency.
Protecting your MSSP benchmark isn’t about chasing some perfect fix; it’s about showing up every 90 days with discipline and intention. That means regularly identifying the right patients, documenting thoroughly, and following through to close any open conditions. It’s not glamorous, but it works. The ACOs and practices that succeed in MSSP are those that treat risk capture as part of their everyday operations, not something they scramble to address at year’s end. Make it a rhythm: flag, document, close the loop, and repeat.
If that sounds like the kind of strategy your team could benefit from, let’s talk. At ChirpyBirdinc.com, we specialize in helping medical practices and ACOs build smart, compliant workflows that don’t just protect your benchmark; they unlock your potential.
Want a 15-minute strategy consult? Contact us today. You’ve got 90 days. We’ll help you make every one count.
