Optimizing Risk Adjustment

Calling the pandemic disruptive to healthcare is an understatement. But, the road ahead offers some unique opportunities to optimize risk adjustment. With the signing of the American Rescue Plan Act of 2021, barriers and premiums for COBRA have been reduced or eliminated, there are new Medicaid expansion incentives, and the ACA marketplace has an off-calendar second opening. Similarly, the pent up demand for care is rebounding patient volumes. Finally, risk adjustable population growth is strong and rising; Medicare Advantage is nearly half of the eligible Medicare population and ACA Marketplace volume is at an all-time high.

The first step is to stabilize revenue and ensure gaps in population RAF capture are closed. Another key to revenue continuity is to focus on identifying missed and under-coded conditions that can return revenue now, for current dates of service. Prospective programs like Edifecs Pre-Visit Prep can be put to work as patient volumes rebound, capturing conditions that were missed in prior years and not just re-establishing prior RAF scores, but going deeper and improving them.

Once revenue is addressed, reducing unnecessary risk adjustment expense is important, especially in light of its standing under MLR rules for payers. Now more than ever, addressing unnecessary expense can solve parallel problems. For example, early on in 2020, it became clear for many organizations that manual record retrieval was a highly cost-prohibitive process that was prone to disruption from the pandemic. Turning to electronic, automated methods for clinical data acquisition makes sense for a number of reasons. Edifecs EMR Link is a fully automated record retrieval solution that applies to more than just risk-adjustment and can remove this systemic vulnerability while also reducing total costs. For organizations operating vital legacy technology that are lagging on upcoming interoperability mandates, EMR Link can become a critical data access point, as well.

Similarly, compliance is yet another layer to consider when optimizing risk adjustment programs. Establishing a two-way coding workflow that ensures submitted claims are complete and accurate via redacting codes that lack clinical evidence will be integral for protecting against audits.

These are just a few ways to refine risk adjustment operations that can help bring your organization some relief from the last year. To really identify the holistic value of risk adjustment to your organization, we recommend performing an assessment, which allows you to build a roadmap to realize your full potential. Whether an organization is undertaking risk adjustment for the first time, or looking to reinvigorate their process, knowing just where to begin can be a challenge. Many of the steps can be interdependent, others may be contradictory in the wrong order, while others are force multipliers, picking up fast revenue to self-fund the initiatives.

We can help you manage those exact challenges, and give you a sense of where to begin. We can help you quantify which of your population segments, provider networks, and condition categories have the most opportunity—enabling targeting prioritization that yields a significant increase in outcomes over traditional methods. Contact us today to get your risk adjustment transformation underway.