Unlocking the True Potential of Your Risk Adjustment Program

With many patients resuming care and the overall uptick in provider visits during the first half of 2021, now is the time to take stock of how your risk adjustment program is performing by aggregating and analyzing numerous data sets. But to unlock the true potential of this data, you will need the right team, tools, and technology in place. If your plan is missing any of these elements, you could be missing out on critical opportunities to deliver high quality care, drive value, and improve program performance.

Based on our analysis and program assessments that included data for over 400,000 members, we found that plans on average showed a risk adjustment factor (RAF) opportunity of 0.535 during the second quarter of 2021 based on year-over-year condition suspecting. That equates to a potential lost revenue opportunity of approximately $428 per member per month (PMPM) if not addressed by year end and does not account for new conditions that patients may have developed.

We also found that 14% of members had no dates of service, and that 43% showed no HCCs in the first two quarters of 2021. HCC recapture rates were as low as 41% for the same period, which suggested a significant opportunity for performance improvement and the delivery of high-quality care.

Recent analysis suggests that 30% of the world’s data is generated by the healthcare sector, and this number is growing faster than in any other industry. Those that can aggregate, analyze, and act on insights from this data will put themselves at a significant advantage, but many struggle with this vital business and clinical function.

Understanding Your Risk Adjustment Program Performance

So, why are payers experiencing these missed opportunities with all the information available to them? In many cases, they may not have the necessary in-house teams to aggregate and interpret their data. Even those utilizing an external analytics partner may be surprised at how much RAF is being left on the table if their vendor does not have the deep risk adjustment experience required to identify RAF opportunities and execute programs. Without these resources and experiences, determining the right strategy and selecting the correct interventions can be challenging and cumbersome, leaving significant room for improvement.

In either case, the question payers should ask as they assess performance is: do we know what to look for or how to act on what we find?

Episource Highlight: Risk adjustment professionals may overvalue the importance of technology and neglect the people who can best utilize those tools. At Episource, our team of analytics experts and strategy directors act as extensions of your team to uncover hidden opportunities and help you turn insights into actions.

The first step to understanding how well your program is performing is to determine what’s working and what’s not — and identify the root causes behind both. With this foundation, you must then build a strategic roadmap that outlines key priorities and action items.

Navigating Your Data

These steps require three core competencies:

• The right team: Having access to your plan’s data isn’t enough. It’s important to have a team that can aggregate that data along with data from the Centers for Medicare & Medicaid Services (CMS) and providers in one place. Whether internal or external, this team must be able to apply their risk adjustment expertise to accurately assess your program, identify areas of opportunity, and propose solutions to make the most of them.
• The right tools: Your team or partners must be able to create a deep analysis of your plan’s performance on all relevant metrics. This analysis may be used to generate an action plan that takes advantage of what you do well and should identify specific solutions and interventions at the member, provider, and plan levels to address any areas of unrealized opportunity. This will allow you to focus on the right interventions and avoid those that produce little to no impact on risk scores or patient outcomes.
• The right technology: Once your plan has been thoroughly assessed, the right technology platform will allow you to take what you’ve learned and implement the proposed solutions in an efficient manner. This platform should have a well-designed user experience (UX) and user interface (UI) so anyone in your organization can easily and seamlessly interact with your data. It should also incorporate coding and programmatic data into your workflow so you can make real-time decisions. This will help you perform faster comparative analysis, supplement existing chase lists with new opportunities as they arise, and deliver more integrated care.

Turning Analytics into Action

As members continue to return to the providers in your system, understanding the nuances of your risk adjustment program performance can improve clinical and financial metrics, and ultimately enable delivery of higher quality care. With each month that passes, there is less and less opportunity to execute the interventions that can make a meaningful impact, and if you do not already have a strategic roadmap in place, you may be surprised at how much potential opportunity you are leaving on the table. The first step is putting together the right team, tools, and technology for future success.

To build your program performance playbook and start turning data insights into action, connect with our team today.

For overburdened payers and providers, Episource helps close gaps in healthcare by marrying expert guidance with an end-to-end risk adjustment platform. Learn more about our solutions at Episource.com.