Risk Adjustment

Risk-adjusted revenue is increasing across government and commercial lines of business.

A lack of an integrated revenue integrity program can have a significant financial impact across your risk-adjusted payment programs.

30% of Medicare enrollees are in the risk-adjusted Medicare Advantage> program1

The 8M Marketplace enrollees are all part of risk-adjustment programs2

24 states have moved their managed Medicaid programs to risk-adjusted models3

Industry experts expect that by 2016, 77% of all Medicaid enrollees will be part of a managed care program (~44M covered lives).

Move from a compliance to a revenue-management mindset:
i.e. – EDPS contributing to 10% of revenue and growing

Deploy prospective and retrospective programs in conjunction with provider engagement programs

Invest in resources to build a strong internal audit program to support RADV and IVA audits

Ensure accurate coding of claims to reflect clinically accurate population risk

Work with health plans to ensure reimbursement models are aligned with risk adjustment programs

Higher levels of risk require more detailed and actionable analytics on data submitted to CMS and states

Key Implementation Capabilities

Risk Adjustment Lifecycle

Successfully execute upon and integrate HRA data, regardless of place of service, towards a more accurate member risk score and profile. Crucial to targeting.

Learn how Edifecs Risk Adjustment can help.

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Retrospective and prospective targeting strategies as keys to a successful risk adjustment programs.

Learn how Edifecs Risk Adjustment can help.

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Successful encounter submissions as vital data to achieve compliance and payment accuracy in risk adjusted programs.

Learn how Edifecs Encounter Management can help.

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Accurate revenue forecasting is based on compliant, complete and accurate data.

Learn how Edifecs Risk Adjustment can help.

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Reconciling membership and payment information between CMS/state and health plan data can materially impact payment accuracy.

Learn how Edifecs Risk Adjustment can help.

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Risk Adjustment Maturity Model

Have you been successful in operationalizing a blueprint that can optimize revenue integrity across your commercial and government programs?

Our experts can help.

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  • WB


    Commercial and Government Program Revenue Integrity–From Model to Motion

    The Edifecs Revenue Integrity Maturity Model is designed to provide a blueprint health plans can follow as they work towards revenue integrity, even across programs. Yet, how do you operationalize this blueprint? How can your plan on moving from one stage to the next?

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  • CS

    Case Study

    Carpe Diem for Health Plans

    New market opportunities abound for health plans. With the advent of the Marketplaces and expanding managed Medicaid and Medicare Advantage rosters, health plans have new options to choose from that will increase their market footprint

    View Case Study

  • CS

    Case Study

    Lessons from the Road to Value and Savings

    An ambitious regional Blue Cross Blue Shield plan needed to embark on a major multi-component strategic initiative. This initiative consisted of achieving specific medical loss and administrative loss ratio goals—as well as compliance with new market laws.

    View Case Study

  • WP

    White Paper

    Risk Adjustment Best Practices 

    High-risk, low-margin health plan products are proliferating throughout the US healthcare system. In recent years, we've seen the advent of the insurance marketplaces and expansion in both managed Medicaid and Medicare Advantage programs. One of the main constants for health plans—across lines of business—is to maintain revenue integrity through the critical practice of accurate risk adjustment.

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1. 30% of Medicare enrollees are in the risk adjusted Medicare Advantage program. Source: CMS

2. In ACA Marketplace commercial programs (on and off exchange) that have 8M enrollees are risk adjusted.
Source: MCOL

3. 24 States have moved their managed Medicaid programs to risk adjusted models focusing more on chronic populations. Source: MHPA