Winning in Risk Adjustment Five Steps for Health Plan Executives to Boost Coding Accuracy and Efficiency

Executive Summary

An educational whitepaper, courtesy of Talix

As the healthcare industry continues to shift from volume-based to value-based reimbursement, health plans are moving to change the way they do business. Recognizing that the cost of and incentives associated with traditional fee-for-service care are unsustainable, they are expanding their risk-based contracting efforts and seeking out more innovative ways to help providers deliver better care at a lower cost. For these payer organizations, accurate and timely risk adjustment is crucial to their success, as it has a direct impact on both plan revenue and care quality. 


The stakes are high and will only continue to grow. In today’s highly regulated, competitive and increasingly quality-focused market, payers must look to technology for cost-effective ways to expand their risk adjustment strategies.

This white paper outlines the risk adjustment challenges health plans face and how technology-enabled data analytics can help plans tackle the problem and master risk adjustment through five proven steps for improved coding efficiency, productivity and accuracy.

A Changing Marketplace

The Center for Medicare & Medicaid Services’ (CMS) goal to tie 50 percent of traditional fee-for-service Medicare payments to quality or value through alternative payment models—such as Accountable Care Organizations (ACO)—by the end of 2018 has drastically changed the Medicare Advantage insurance marketplace. Healthcare consulting firm Leavitt Partners predicts that by 2020, anywhere from 41 million to more than 176 million patients will be covered by a value-based contract delivered through an ACO, with MACRA payments responsible for 37 million of those1. Similarly, the passage of the Affordable Care Act (ACA) has touched off a dramatic shift toward value-based care in the commercial health plan market. 

Payers in both markets are responding to the increasing demand for higher quality and more affordable care by veering away from simply paying for treatment to supporting prevention and wellness efforts through value-based care and population health management initiatives. Payers surveyed in a recent national research study commissioned by McKesson2 estimated that 42 percent of their payments will be tied to value-based reimbursement models in the next two years, up from 32 percent currently. That number rises to 54 percent of payments tied to value-based reimbursement arrangements in fi ve years. Goodbye fee-for-service care, hello value-based, risk-adjusted care. 

This white paper continues.  Please download entire white paper from this link


Categories: Risk Adjustment
Tags: risk adjustment, ACO, MACRA, FFS

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