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Modern Day Risk Adjustment Reimbursement

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February 24, 2022

It’s no secret that health plans have been under increasing Federal pressure to validate payments and avoid timely audits such as RADV. Historically, retrospective data reviews for a subset of a plan’s roster have been the source for submissions to CMS. Because reimbursement is established based on assumed risk, a partial subset review could mean risk scores that are grossly inaccurate. Throw in a beating drum for validating compliance, a government atmosphere seeking to control costs while wishing to expand access, continued focus on value-based care / proactive member engagement, and pressure to maintain and grow revenue by plans – and the stage is set for risk adjustment transformation.

How can Health Plans meet all these expectations without changing their approach or adopting new technologies? They simply cannot—plans need to solve for risk adjustment blind spots using a member-focused retrieval of information.

Key considerations for risk adjustment transformation

Of the $11,844 industry average per Medicare Advantage enrollee and equally, as relevant to ACA, Medicaid, and Commercial; how much additional revenue might a plan be missing, or un-intentionally being overpaid which results in time-consuming post-submission audits? Stated differently, a plan needs to be funded commensurate with the needs of the entire base – but traditional approaches do not enable a full understanding of the entire member base.

  • How to follow members who switch physicians? Baby Boomers switched doctors at a rate of 35% over two years according to a 2017 report.
  • For existing plan members, missing risk adjustable codes as they see new physicians or switch physicians is common
  • How about New Members? According to, about 26% of respondents said they were likely to switch Medicare Advantage plans. For new members, how much (or little) do you know about them?
  • Using actual client data, it was discovered about 5.4% of members in February were not on the January roster
  • Consider how many new members in your roster you could retrieve information for
  • Even for your recurring members, why limit retrieval efforts to only a handful of the physicians you ‘know’ about?
  • By looking at ‘more physicians’ a recent pilot found RA codes for members (Identified risk adjustable codes not found with prior attempts by customer) resulted in 16.1% increase in Risk Adjustable above what was found in prior attempts.
  • When asked about the pilot results, “Are they incremental to other sources? Or gross findings?” Customer reply: “Yes, incremental prior to submission. We screened out codes from other sources (or at least attempted to)”.
  • Beyond Risk Adjustment, retrieving more comprehensive clinical and social determinants information about your entire member base enables you to identify and provide targeted member services that drive outcomes-based care (clinical and cost outcomes).

A Member Locator approach reduces risk adjustment vulnerabilities

In summary, using a Member Locator approach for your entire member base can address many of the challenges the old “retrospective” way of doing things cannot. For risk adjustment submissions, ensuring you have the right codes identified and validated reduces the risk of submitting incorrectly and being subject to audits and Federal scrutiny. Changing to a member-centric approach sooner than later will optimize the impact on your health plan and your ability to support your members.

With Datavant Health Data Retrieval, determine individual member chart availability across the provider network to acquire charts across a broader provider population. Expand visibility past one specific provider such as PCP or specialist to the patient’s comprehensive care network. Eliminate reliance on a sole encounter and select the charts most dependably accessible to support risk adjustment and proactive member engagement.

Health Data Retrieval offers an innovative approach to “look before you leap,” electronically retrieving as many charts as possible for all members and shifting away from the traditional process of targeting specific member sub-sets.

  • Reduce reliance on traditional retrieval, which requires more effort and is less provider friendly
  • Fill the gaps and improve data quality for risk adjustment code capture
  • Simplify the retrieval process by accepting records directly retrieved from EHRs in Continuity of Care Documents (CCDs) or Clinical Document Architecture (CDA) formats
  • Collect data very quickly and efficiently at the Provider and Member levels

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