A successful risk adjustment strategy allows risk-bearing entities to better manage their financial health by strengthening both the top and bottom line. The prospective nature of risk adjustment doesn't just ensure more accurate payments sooner but also helps to control costs through smarter resource allocation and more accurate financial forecasting.
But the benefits of a prospective risk adjustment workflow expand well beyond just revenue cycle management. The shift to proactive workflows that risk adjustment programs require has a significant impact on an organization's day-to-day operations. The often underestimated organizational benefits of risk adjustment include:
Healthcare organizations that have assumed accountability for patient populations collect comprehensive data in order to adjust for risk. These more robust patient profiles, especially when collected prior to patient visits, have a significant effect on operational efficiencies. Advance knowledge of which patients require extra time and attention makes the day go more smoothly. Encounters are meaningful and well organized, which not only improves provider productivity but ultimately, outcomes and the patient experience.
Aligning operations to the prospective nature of risk adjustment encourages providers to document and code more accurately in the first place, which reduces the need for retrospective audits, saving organizations future administrative burden.
While incorporating prospective workflows often means more upfront work, that investment saves organizations a much more resource intensive and expensive administrative burden in the future. As provider organizations know all too well, the disruptive and random nature of retrospective audits ties up far too much precious time and resources that are better spent on patient care and other initiatives, particularly during the 4th quarter rush.
Risk-based organizations need accurate measurements of outcomes, processes, and costs to forecast the cost of care and meaningfully improve the quality and efficiency of care delivery. Most organizations realize that the adoption of new technologies is required to support these initiatives. The traditional methods of hunting through charts manually are no longer enough to stay competitive in this environment. Especially when technology is rapidly evolving in ways that can exponentially increase the productivity and accuracy of risk adjustment workflows. Healthcare leaders are now increasingly making use of artificial intelligence (AI), machine learning (ML), remote patient monitoring (RPM) and next-generation diagnostic tools to calculate risk, prevent health crises and target interventions more precisely.
Risk adjustment in healthcare has evolved into much more than an actuarial exercise. The systemic changes that organizations go through to meet the demands of managing risk can have a significant and far-reaching impacts on day-to-day operations and long-term sustainability.
Payers in value-based contracts are expected to move beyond their traditional role as insurance purveyors and assume the broader responsibility of improving outcomes and care coordination. Claims data is not a sufficient foundation for successfully fulfilling this role. By leveraging the valuable insights and real-time availability that clinical data offers, plans can carry out the level of proactive outreach and crises prevention that value-based care management demands.
AI is no replacement for human judgement but it can go a long way towards simplifying and streamlining data management and analysis. AI-enabled chart review helps providers and plans that coordinate care for complex populations work smarter, not harder, by shifting the focus from volume of charts targeted to precision targeting of charts.
The Centers for Medicare & Medicaid Services (CMS) initiated the Hierarchical Condition Category (HCC) model in 2004 to adjust payments to Medicare Advantage Organizations (MAOs). The model has been more prevalent in recent years as HCCs are becoming more widely recognized as one of value-based programs' most important components. This heightened visibility is due in large part to the growth and success of Medicare Advantage.