The Importance of Prospective Risk Adjustment in Healthcare

In an ever-evolving healthcare landscape, effectively managing risk is crucial to improving patient outcomes and reducing costs. One of the most promising strategies in this regard is the adoption of prospective risk adjustment. Unlike retrospective risk adjustment, a prospective strategy exposes potential and confirmed chronic conditions before the patient visits their doctor, giving the care team time to prepare for, address, and treat serious conditions. By closing care gaps and intervening earlier, providers ultimately enhance the quality of care.

Data silos and manual processes often prevent prospective programs from achieving their full potential. The successful implementation of prospective risk adjustment requires collaboration and data sharing between payers and providers, as well as technology that is capable of analyzing unstructured data within the EMR.

Interoperable technology solutions, like FHIR® or robotic process automation (RPA), support operational efficiency and reduce costs. Other efficiency-building strategies include the introduction of natural language processing (NLP) trained on vast amounts of healthcare-specific data, which works to minimize errors and unnecessary reviews. Another strategy involves enhancing clinical condition suggestions with confidence scoring to ensure care teams are prioritizing their work queues appropriately. Finally, facilitating collaboration with payer partners is critical; fostering a culture of trust and transparency is foundational to building strong partnerships. By working together and embracing prospective approaches to risk adjustment, healthcare organizations can improve patient outcomes, reduce costs, and create a more sustainable healthcare system.

At Edifecs, we understand the importance of collaboration between payers and providers, and our Value-Based Payment & Insight solutions are designed to deliver the transparency and clarity needed to thrive in value-based care programs. We also know that collaboration has to be supported by action, which is why we designed our Risk Adjustment Clinical Suite to help provider organizations and their payer partners intervene earlier to close open risk adjustment gaps and optimize patient care and outcomes.

To learn more about how technology can support prospective risk adjustment, watch a clip from our webinar.