Risk Adjustment Analytics

Apply Precision Risk Adjustment Analytics to Managed Medicaid, Affordable Care Act (ACA) Commercial, and Medicare Advantage Markets

As the healthcare industry continues its shift toward value-based care, health plans and payers are increasingly focused on avoiding administrative waste and promoting quality patient health outcomes. Precision risk adjustment analytics help health plans and payers reach these goals by providing four key benefits:

  • Periodically confirming the presence of chronic illnesses and preexisting health conditions in members.
  • Collating evidence to aid detection of unconfirmed, unsubmitted patient diagnoses.
  • Leading to earlier, more appropriate treatment of affected members.
  • Allowing precise, efficient targeting of risk adjustment interventions.

Veradigm’s Risk Adjustment Analytics solution (formerly Calcul8) delivers precise, advanced risk adjustment algorithms that are built from broad data sets for superior accuracy. Risk Adjustment Analytics enables health plans and payers to actively manage success with Managed Medicaid, ACA Commercial, and Medicare Advantage lines of business.

Navigate Your Financial Monitoring and Gap Closures with a Single Risk Adjustment Analytics Solution

  • Provides the near real-time visibility needed to monitor and manage risk adjustment revenue against budgeted gap closures and Key Performance Indicators (KPIs).
  • Reports current, trending, and available opportunity risk scores on the Standard Risk Adjustment Analytics dashboards.
  • Displays a population-level view of gap closure opportunities.
  • Supplies a big-picture overview of gap closure opportunities displayed by contract, risk adjustment factor, condition type, or confidence level.
  • Identifies and calibrates the confidence level for each gap closure opportunity.
  • Prioritizes all possible gap closure opportunities using confidence-adjusted risk scores.
  • Saves money by identifying the most profitable gap closure opportunities.

Identify Optimal Intervention Strategies for Gap Closure Opportunities

Veradigm’s Risk Adjustment Analytics identifies gap closure opportunities through use of multiple predictive models based on the most current Risk Adjustment and Hierarchical Condition Category (HCC) methodology. It utilizes Big Data mining, clinical inferencing, and predictive models to create algorithms considering a wide range of information:

  • Medical records
  • Lab results
  • Medical and pharmacy claims
  • Health assessments
  • Other off the data grid information

Risk Adjustment Analytics scores and calibrates the confidence level for each opportunity based on member and provider behavior patterns combined with the frequency, potency, and reliability of each data source.

Pursue the Right Member and the Right Provider with the Right Intervention at the Right Time

Accurate diagnostic coding is critical for both health plans and patients. Despite this, diagnostic coding errors are common. Studies show that:

  • ICD-10 coding in patient medical records can have error rates ranging from about 20% to 50%.
  • More than 40% of patients’ chronic conditions are never reported.
  • About 30% of claims with accurate patient diagnoses fail to pass the CMS validation process due to insufficient supporting documentation.

Veradigm’s Risk Adjustment Analytics enables detection of these and other types of errors with patented Dynamic Intervention Planning, recommending optimal strategies for efficiently closing each gap worth pursuing.

Actively Manage Success with Veradigm’s Risk Adjustment Analytics

Risk Adjustment Analytics Financial Reporting Suite enables monitoring of performance, helping risk-bearing entities navigate the complexity of financial reporting. It has the capacity to:

  • Predict Medicare Advantage Mid-Year Risk Adjustment or Final-Year Risk Adjustment impact.
  • Use the ACA Commercial Modeler to calculate the Risk Adjustment Factor (RAF) Points.
  • Monetize ACA Gap Closures as contributions to year-end risk transfer payments.
  • Project the impact of revenue and risk scores for each contract.

Veradigm’s Risk Adjustment Analytics can help to increase financial reimbursement in all lines of business.

References:

  1. Wrathall J, Belnap T. Reducing Health Care Costs Through Patient Targeting. EGEMS (Wash DC). April 20, 2017;5(2):4. doi:10.13063/2327-9214.1279.
  2. Weed K. Why Are My RAF Scores Low? RCxRules. Updated August 20, 2019.
  3. Cassano HJ. Factor HCC with a Two-pronged Approach to Risk Adjustment. Advancing the Business of Healthcare (AAPC). Updated August 1, 2012.