What is the value of risk adjustment?

Health plans need to be able to leverage the most updated, comprehensive member healthcare data in order to accurately make informed decisions about population health analytics, cost prediction, required internal reporting, resource investment, and longitudinal performance analysis.

Retrospective risk adjustment enables a health plan to identify and report member health conditions directly to Centers for Medicare and Medicaid Services’ (CMS) without additional health care provider involvement. This has been a popular approach with insurance organizations as it eliminates the need to engage providers and request additional documentation or clarifications.

In contrast, prospective reviews look for clues referred to as “Clinical Indicators” before a physician meets with the patient in an effort to eliminate potential care gaps and help improve patient outcomes. Learn more about retrospective and prospective risk adjustment reviews.

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Three strategies for health plans engaged in risk adjustment
Risk adjustment plays a significant role in Medicare Advantage (MA) contracts and commercial exchange plans, as well as CMS alternative payment models. Learn about three strategies that can help plans engaged in risk adjustment to ensure compliance and optimize financial success.
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Our approach to improving risk adjustment workflows

Learn About Health Language Risk Adjustment

From optimizing risk adjustment workflows to employing risk adjustment strategies to leveraging cutting edge technologies, improving accuracy and efficiency requires quality data, organization, and tools. Explore how we approach these challenges.

  • Optimizing HCC risk assessment

    Risk adjustment plays a significant role in Medicare Advantage (MA) contracts and commercial exchange plans, as well as The Centers for Medicare and Medicaid Services’ (CMS) alternative payment models.

    Hierarchical Condition Categories (HCC’s) are used in contracts with MA plans. Higher HCC scores identify more complex patients and allow for additional payment from CMS to care for those patients.

    Learn More About HCCs →

  • RAF scores and retrospective review

    Risk Adjustment Factor (RAF) scores are based on diagnoses. RAF scores determine the amount paid to the organization per beneficiary during the corresponding payment year. Insurance organizations are paid at a higher rate for patients that have multiple conditions and conditions with greater levels of severity, as their anticipated costs of care will be higher.

    Retrospective reviews use strict criteria to identify diagnoses that are eligible for reporting. Without retrospective review, healthcare organizations may find themselves out of compliance with HCC coding guidelines.

  • RADV compliance and audits

    RADV and OIG audits are increasing. Health plans are under more pressure than ever to ensure their risk adjustment (RA) programs are accurate and efficient.

    RADV audits are extremely involved and a fixed deadline is set by CMS. As a stand-alone or when combined with other Health Language Expert Solutions Suites, Health Language helps health plans standardize claims and clinical data and provides the tools for more efficient workflows, increased efficiency and production, more accurate RAF scores, higher RADV validation results, and contributing to better member care and outcomes.

    Read Seven Strategies For A Successful RADV Audit →

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Health Language Risk Adjustment
The Health Language Risk Adjustment Solution leverages AI, machine learning, optical character recognition, and clinically tuned natural language processing (cNLP) to support clinical validation. The Coder Workbench workflow tool abstracts valuable diagnoses, clinical indicators, and metadata from unstructured medical documents, resulting in higher accuracy, superior data organization, increased production, greater visibility, and meaningful analytics.
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Resources for improving risk adjustment workflows

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Leverage the right technology to optimize risk adjustment workflows
In this RISE Association webinar, Wolters Kluwer risk adjustment experts offer both provider and health plan perspectives on existing risk adjustment workflows and coding practices, and discuss room for improvement.
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Understanding the RADV final rule from a medical coder
CMS issued the final rule that determines the repayment methodology for errors found from RADV audits. Learn about the impacts of the RADV final rule and our keys to improving the accuracy of risk adjustment coding.
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Additional expertise on risk adjustment

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Prospective reviews in risk adjustment: The hunt for clinical indicators
Two of the more commonly used approaches for identifying unreported diagnoses include “retrospective” chart reviews, and “prospective” information reviews. The two approaches are complementary but have key differences which are outlined in this article.
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Seven key strategies for a successful RADV audit
Medicare Advantage Organizations (MAOs) are under increasing scrutiny for accuracy in RADV audits. Read seven tips for contract-level RADV audits from a certified coder.
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Clinical NLP: Spotlight on Risk Adjustment
Learn about how clinical NLP supports risk adjustment, see examples of risk calculation adjustments, understand the challenge of extracting insights from unstructured data, and read about common use cases.
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