What is the value of risk adjustment?

Health plans need to be able to leverage the most updated, comprehensive member healthcare data in order to accurately make informed decisions about population health analytics, cost prediction, required internal reporting, resource investment, and longitudinal performance analysis.

Retrospective risk adjustment enables a health plan to identify and report member health conditions directly to Centers for Medicare and Medicaid Services’ (CMS) without additional health care provider involvement. This has been a popular approach with insurance organizations as it eliminates the need to engage providers and request additional documentation or clarifications.

In contrast, prospective reviews look for clues referred to as “Clinical Indicators” before a physician meets with the patient in an effort to eliminate potential care gaps and help improve patient outcomes. Learn more about retrospective and prospective risk adjustment reviews.

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Our approach to improving risk adjustment workflows

From optimizing risk adjustment workflows to employing risk adjustment strategies to leveraging cutting edge technologies, improving accuracy and efficiency requires quality data, organization, and tools. Explore how we approach these challenges.

  • Optimizing HCC risk assessment

    Risk adjustment plays a significant role in Medicare Advantage (MA) contracts and commercial exchange plans, as well as The Centers for Medicare and Medicaid Services’ (CMS) alternative payment models.

    Hierarchical Condition Categories (HCC’s) are used in contracts with MA plans. Higher HCC scores identify more complex patients and allow for additional payment from CMS to care for those patients.

    Learn More About HCCs →

  • RAF scores and retrospective review

    Risk Adjustment Factor (RAF) scores are based on diagnoses. RAF scores determine the amount paid to the organization per beneficiary during the corresponding payment year. Insurance organizations are paid at a higher rate for patients that have multiple conditions and conditions with greater levels of severity, as their anticipated costs of care will be higher.

    Retrospective reviews use strict criteria to identify diagnoses that are eligible for reporting. Without retrospective review, healthcare organizations may find themselves out of compliance with HCC coding guidelines.

  • RADV compliance and audits

    RADV and OIG audits are increasing. Health plans are under more pressure than ever to ensure their risk adjustment (RA) programs are accurate and efficient.

    RADV audits are extremely involved and a fixed deadline is set by CMS. As a stand-alone or when combined with other Health Language Expert Solutions Suites, Health Language helps health plans standardize claims and clinical data and provides the tools for more efficient workflows, increased efficiency and production, more accurate RAF scores, higher RADV validation results, and contributing to better member care and outcomes.

    Read Seven Strategies For A Successful RADV Audit →

Resources for improving risk adjustment workflows

Additional expertise on risk adjustment

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