August 24 2016 | 0 Comments | 298 reads Average Rating: 3

Risk Adjustment: Making the Most of Payment Opportunities

by SCIO Health Analytics in Risk Adjustment

H. Jackson Browne, Jr., author of the inspirational bestseller, Life’s Little Instruction Book, which contained 511 reminders about how to live a happy and rewarding life, once said: "Nothing is more expensive than a missed opportunity."

Healthcare organizations can relate to this truism, as many are missing the opportunity to collect additional reimbursement through risk adjusted payments, which offer increased payments for treating patients with one or more chronic conditions. For example, if Medicare Advantage normally pays $800 per member per month (pmpm) to the health plan, risk adjustment for a member who has diabetes with complications might be three times that amount.

For healthcare organizations to collect these higher payments, providers must treat multiple conditions and document the services. So, when a diabetic patient with a sprained wrist comes in for treatment, the clinician must address both health issues. If the clinician doesn’t have information about the patient’s previous history, however, he might simply concentrate on the sprained wrist – and neglect to address the diabetes. As such, the opportunity for increased reimbursement is missed.

When health plans and providers work from the same set of data, they can collaborate to improve member health as well as risk scores and reimbursements. In fact, analytics can be applied to this combined data to enable healthcare organizations to take advantage of opportunities by:

#1: Recognizing when opportunities knock

If the physician has information about the patient’s previous history available at the time of care, they can deliver needed services such as an eye/foot exam for a diabetic – even if the patient is presenting with a sprained wrist. By analyzing data from both provider and payer databases, such opportunities can be identified – and care gaps can be avoided.

#2: Encouraging patients to do the right thing

Through analysis, healthcare organizations can identify the highest-risk patients/members and prioritize which ones should be contacted for immediate visits, how they should be contacted and which organization (payer or provider) should manage the process depending on their resources and known patient/member preferences.

#3: Glimpsing into the future

Through an analysis of the data, organizations can identifying patients/members who may not have qualified for higher risk scores before but are on a path toward qualifying in the near future. Payers and providers can combine their efforts to help those patients/members stay healthier and avoid the need for a greater level of care. This strategy not only benefits the patient/member; it cuts down on the level of care and documentation required.

These are just a few ways that analytics can help healthcare organizations take advantage of risk adjustment opportunities. Can you think of more?

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