Medicare Risk Adjustment

With the RISE Nashville Summit shrinking in the rearview mirror but still fresh in our collective memories it’s time to act on what we learned from our peers and expert presenters.  In the spirit of full disclosure, this was my first time attending RISE Nashville so my experience is likely much different than a veteran event goer.  My AHA! moment came sometime toward the end of the second day when I found time to peruse the exhibit floor.  I was struck by how relatively few exhibitors offer enterprise level technology specifically focused on risk adjustment.  Now, many will rightly point out the bevy of data analytics companies, so let me explain. 

Most of my healthcare career has been spent selling and implementing large scale claims processing and care management systems.  These systems support the core processes of a health plan and are considered business critical.  If a plan can’t enroll members, bill premium or pay claims, they don’t have much of a business.  In fact, these systems are so essential that the mere suggestion of replacing or outsourcing them is sure to trigger a boardroom discussion. 

I think most would agree that this year’s Summit further crystalized the notion that risk adjustment is vital to a plan’s survival in the new healthcare economy.  Yet many of the folks I spoke with in Nashville bemoaned the lack of resources, the size of their teams, the amount of manual work, poor communication and difficulties securing the requisite level of IT support.  This simply won’t do as reimbursement models continue to evolve.

Recall that in January of 2015 HHS announced that by 2018 90% of Medicare Fee-For-Service payments will be linked to quality and alternative payment models such as bundled and population-based payments [click here for the CMS fact sheet].  Success in this new healthcare economy will depend on reconciling complex information from disparate sources (i.e., enrollment, eligibility, benefit, claims, care management systems, EMRs) and making it available for just-in-time decision making.  Few plans can honestly say they have the systems, processes or people to pull this off.

I’ll stipulate that working for a software company I tend to view the world through a technical prism but it seems to me conditions are ripe for innovation.  No doubt plans need sophisticated analytics tools to make sense of mountains of financial, clinical and performance data but that’s only one piece of an increasingly complex puzzle.  Going forward risk adjustment will require systems and tools that facilitate collaboration with revenue management, care management, provider services, I/T and other disciplines.   

As is usually the case plans are beginning to adapt to market forces.  Over the past year we’ve seen more plans take steps to harmonize their quality and risk adjustment initiatives. Some are merging resources under a single business owner while others are opting for dotted line matrixed teams.  Many plans are exploring technical solutions for streamlining processes and improving access to data. 

For our part we will continue to incorporate what we learn from events like RISE and from our clients into our products.  We recognize that we can’t be all things to all people so we will continue to bring news and insights gleaned from the front lines where innovators tackling the challenges navigating an ACA driven healthcare economy.  Meantime, please send me your thoughts.

  • What are the most significant impediments to improving risk adjustment precision and Stars ratings?
  • Are plans dedicating sufficient resources to risk adjustment and quality initiatives to ensure success?
  • What technical innovations are necessary to facilitate collaboration across disparate business functions?

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About The Author

Reveleer is a healthcare software and services company that empowers payers in all lines of business to take control over their risk adjustment and quality improvement programs. The Reveleer platform enables payers to independently execute and manage every aspect of provider outreach, retrieval, coding, abstraction and reporting – all under one single platform. Leveraging its technology, proprietary data sets, and subject matter expertise, Reveleer also assists payers with full record retrieval and review services to support financial performance and improved member outcomes.