Risk Adjustment

Risk adjustment: How to improve health plan performance by eliminating data challenges

Sandeep Gupta
Tue 09 February 2021
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Risk adjustment enables payers to assess the health status and expected costs incurred by each member. Risk adjustment can correctly project the patient’s health profile and need for services that can ultimately help in achieving improved health outcomes in a cost-effective manner.

Timely access to accurate data is critical in the process of risk adjustment. Its absence can lead to penalties resulting from errors in encounter data submissions, infrequent, or inadequate reporting. The consequence of improper data submission could mean failing audits, repaying the Centers for Medicare and Medicaid Services (CMS) and even legal implications.

Data challenges causing obstructions in risk adjustment

To calculate the reimbursements and the risk adjustment scores accurately, it is important to capture and document comprehensive patient data for the attributed members. However, there is some information pertaining to a member’s health status and risk that cannot be elicited from the claims data alone. For that matter, clinical data also may not be enough to project a member’s lifestyle choices that can adversely affect their health.

There are numerous data sources such as billings, labs, pharmacy, medical equipment, wearable devices apart from traditional data sources like electronic health records and claims data that can reveal significant information about a member’s health. However, incorporating increased volumes of data, stored in different formats can be difficult, time-consuming and expensive.

Beyond storage, there are other requirements such as integrating the data, retrieving particular data sets as needed and sharing the data between different stakeholders. Unstructured data, no matter the volume, can reveal no insights about the members, their health risks and their health status. There is a need to standardize the data and apply advanced analytics to get information that can be leveraged to calculate members’ risk scores.

Improving risk-adjustment with a FHIR-enabled Data Activation Platform

Leveraging a FHIR-enabled Data Activation Platform, payers can access and integrate data from disparate sources and apply analytics to impact the bottom line of a health plan, improve population health management and make informed decisions about premium pricing, membership expansion, bid rate calculation, etc. It also provides real-time feeds on patients to providers and assists them in identifying complications, co-morbidities, medications, etc.

It can help payers in identifying missed diagnosis codes or potential down-coding to analyze the tangible impact on revenue and risk-adjusted savings. It streamlines the data documentation process using built-in analytics and risk coding with flexible and automated workflows. In addition, it can help healthcare networks justify admission and treatment, accurately reflect the severity of medical conditions and accurately assess their risk which, in turn, will be instrumental in generating better financial outcomes.

To learn more about improving risk adjustment with Innovaccer’s Healthcare Data Platform for payers, get a demo.

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