Chart Reviews - Prospective Vs. Retrospective

Chart Reviews - Prospective Vs. Retrospective

Historically, Medicare Advantage Organizations (MAO’s) have relied on retrospective chart review as the primary method of discovering conditions that may not have been coded during the patient encounter. But with the shift to value-based care, emphasis on early intervention and growing regulatory pressure to get coding and documentation right on initial claims, risk-based payer and provider organizations are increasingly incorporating prospective reviews into their workflows.

Retrospective reviews remain necessary and important - the goal is not to cut out the retrospective process but rather to put an increased focus on strengthening prospective processes. Prospective and retrospective risk adjustment are two sides of the same coin, and the efforts must be coordinated.

By investing in resources and incentives that encourage providers to document and code more accurately in the first place, there will be significantly less need for comprehensive retrospective reviews. The focus of retrospective review can then be narrowed down to ensuring compliance and verification of conditions reported on claims, rather than hunting through documentation to discover potential diagnoses.

The most obvious benefit of prospective review is enhanced revenue cycle management - preventing incorrect claims from going out in the first place reduces the chance of denials and results in quicker more accurate payments.

Getting the coding and documentation right before claims submission with prospective review decreases the number of charts that need to be audited, saving organizations future administrative burden. When treating physicians incompletely document patient disease burden by undercoding or miscoding patient encounters, an expensive cycle of retrospective audit is required. Medical practices know all too well that responding to these requests for documentation are a disruptive, resource intensive and mostly manual process that leaves less time to focus on patient care and other initiatives - particularly during the 4th quarter rush.

A prospective approach not only saves time and money but also serves as a vehicle for growth by shifting the focus from just fixing errors to overall process improvement.

Since the retrospective approach reviews charts later down the line, root causes are left unaddressed for much longer and there is a higher likelihood of the same clinical documentation issues repeating. Prospective reviews, on the other hand, are an opportunity to improve clinical documentation and coding practices across an organization, identify and track root causes of gaps and pinpoint strategies for improvement going forward.

Retrospective chart reviews also offer no clinical benefit. Analysis happens months after patient encounters - so the assessment is already out-of-date before it’s even assembled. The results of this analysis only provide a measure of health statuses from the previous year. Conducting prospective reviews, however, does have a significant effect on the quality of care. A prospective approach establishes accurate benchmarks and patient acuity baselines, which can be used to inform education and intervention efforts. And during encounters, charts that have been prepared prospectively enable physicians to address all relevant conditions and target interventions more precisely.

In today's environment of increased scrutiny, the reality is relying on just on type of review will not be enough to maintain compliance and accuracy. Most organizations find they can strike the right balance by incrementally adopting a more prospective approach while limiting retrospective reviews to validation and compliance when needed.