Prospective risk scores are trending lower than forecasted because routine medical services have been canceled or postponed due to COVID-19. Providers should see an increase in demand for elective and routine care as time goes on, but pandemic precautions have limited capacity and may therefore continue to impact risk adjustment and quality scores.

With more limited face-to-face encounters, providers can and have leveraged telehealth and remote care practices to help reduce the potential negative impact of the pandemic on risk adjustment and quality measurement programs.

A year-over-year comparison of risk scores from 2019 to 2020 can be performed to look for variation in understanding how this change in routine visits is impacting risk adjustment scores. Providers may not see more patients on a routine basis for some time, even as the pandemic lessons once a vaccine is deployed. And when face-to-face primary care does resurge, physicians and other health care providers with limited availability to deal with pent-up demand may prioritize seeing sicker patients, further impacting risk adjustment scores.

According to the latest data from FAIR Health’s Monthly Telehealth Regional Tracker, telehealth claim lines increased 2,980 percent nationally from September 2019 to September 2020, rising from 0.16 percent of medical claim lines in September 2019 to 5.07 percent in September 2020.

However, virtual care claims volume fell from a high of 13.0 percent in April 2020 to the 5.07 percent in September 2020 as states have resumed in-person treatment for non-emergency medical care, allowing patients to return to their doctor. Nonetheless, telehealth usage remains extremely high compared with pre-COVID-19 utilization.

Beyond the COVID-19 pandemic, remote access can continue to provide services to those who are medically vulnerable or who do not have ready access to providers. Remote access can also support the patient-provider relationship at times when an in-person visit is not feasible.

According to CMS, in order to meet the risk adjustment face-to-face requirement, diagnoses resulting from telehealth services must be provided using an interactive audio and video telecommunications system that allows real-time interactive communication. On June 5, the National Committee for Quality Assurance (NCQA) announced permission for telehealth capture of 40 HEDIS® measures, allowing telehealth to address both risk adjustment and quality gaps.

Although telehealth is set up for success, providers do struggle with effective “face-to-face” telehealth delivery. Currently, audio-only (telephonic) telehealth visits cannot be used for risk adjustment consideration. NEJM Catalyst found that telephonic care is the current telehealth mainstay while video-based visits are taking time to ramp up. Ongoing barriers to video-based care include:

  • Training clinicians
  • Explaining arrival procedures to patients
  • Using interpreter services
  • Getting video equipment to clinicians’ homes

The publication also noted that some attempted video visits have had to be switched to the telephone or less HIPAA-compliant platforms such as FaceTime and Skype.

In review, providers should continue perfecting the telehealth model and continue to treat sick members wherever they are.

Having qualified nurse practitioners and physician assistants to reach members in their homes is critical to substantiate and round-out risk adjustment efforts, particularly during a pandemic, but this can be difficult to execute. That’s why Persivia offers telehealth functionality to our risk adjustment services. Learn how we support telehealth to improve prospective risk adjustment results and close care gaps at

The author, Mansoor Khan, is the CEO of Persivia, Inc.