RISE National 2024: What We Learned

The annual RISE National Conference offers an opportunity for mid- to senior-level executives from managed care organizations (MCOs) to come together, share insights and perspectives, and learn about the trends and technologies shaping the healthcare industry. Here are some of the key insights we learned at RISE National 2024.

OIG: MCOs Must Do Better

RISE National 2024 featured keynote addresses from the OIG, DOJ, and CMS on the regulatory landscape. In her address, Inspector General Christy Grimm reiterated that no one is immune from regulatory scrutiny, and the OIG is prepared to investigate and penalize any healthcare organization or vendor that fails to comply with CMS guidelines.

Overall, this year’s message was similar to last year’s: MCOs are on thin ice. Risk adjustment and prior authorization are still not working as intended, and MCOs must focus on shoring up their processes in both areas to avoid financial penalties or even prosecution.

Prospective Risk Adjustment: The Next Frontier

Retrospective reviews are an effective risk adjustment tool, but their utility is limited to correcting errors in bills that have already been submitted for payment. To boost risk adjustment operations, healthcare organizations need to focus on preventing these errors, rather than just fixing them after the fact.

RISE 2024 featured a number of vendor-led breakout sessions that focused on the importance of moving away from retrospective reviews and taking a more proactive approach through prospective risk adjustment. Our Risk Adjustment Clinical Suite offers multiple ways for providers to work together before, during, or after the patient encounter to effectively close diagnosis gaps in value-based arrangements.

Payer-Provider Collaboration Challenges

To ensure full compliance and deliver on the promise of value-based care, payers and providers need to work together; unfortunately, that collaboration doesn’t happen as often as it should. Improving alignment between payers and providers was another key theme at RISE National 2024, and there were a lot of productive conversations about how technology—like our Value-Based Payment & Insights solutions—can help achieve that.

Leveraging AI Technology for APM Success

At RISE 2024, Edifecs CMO Summerpal Kahlon moderated a discussion with Jennifer Holman (Director of Risk Adjustment Programs at Centene) and Deepak Sadagopan (COO of Population Health at Providence).

 

In a lively and informative conversation, Summerpal, Jennifer, and Deepak took a look at the ways AI technology can support risk adjustment by:

• Ensuring compliant diagnosis and coding gap closure
• Utilizing predictive data for risk stratification and chronic disease progression (a particular area of interest for our audience; 48% of attendees polled cited these areas as most critical to APM success)
• Engaging clinicians at the point of care to support accurate diagnosis and documentation

For a deeper dive on AI’s transformative potential in healthcare, be sure to download our recent white paper. We also took a closer look at how NLP technology can help ensure risk capture compliance in this blog post.

The key takeaway from RISE National 2024 was clear: payers and providers need to do more to adapt to a changing regulatory landscape. To learn how Edifecs can support your organization in navigating this transition, get in touch with our team today.