Electronic Health Reporter

By Vinitha Ramnathan, senior vice president of product management, Episource.

Digital transformation is responsible for a lot of very promising innovations in healthcare. From telemedicine to AI-enabled medical devices to NLP-driven coding, technology is reshaping how patients interact with providers, how data is shared, how care decisions are made, and how population risk is managed.

But implementing new technology can be a tall order for such a complex and overburdened industry. Perhaps this is why only 7% of healthcare and pharma organizations surveyed said they had “gone digital.” As more healthcare organizations move into value-based care, embracing a digital mindset will be critical to meeting the ever-changing needs of patients — and that starts with data.

The Importance of Data

Like in any industry, health plans require large amounts of data to improve performance over time. However, data is only as valuable as the information that can be gleaned from it. Due to the explosion of healthcare data, it can be difficult for plans to put this valuable information to work. COVID-19 has exacerbated this problem, increasing telehealth visits 38 times over pre-pandemic levels. This trend is predicted to continue, as experts project that $265 billion in Medicare fee-for-service and Medicare Advantage care services will be done at home by 2025.

Partnering with a risk adjustment vendor can help health plans and risk-bearing providers see beyond the data weeds. Partnering with multiple vendors, however, can actually contribute to the problem, leading to siloes, disjointed workflows, and reduced visibility into key metrics.

To solve this, a growing number of healthcare leaders are streamlining workflows and replacing individual solutions from multiple vendors with a single, integrated tech stack. This platform approach can result in more accurate risk scores, reduced provider abrasion, and improved patient care. To help health plans do just that, we’ve outlined four key attributes to look for in a risk adjustment partner.

Characteristics to Look for in a Risk Adjustment Partner

1. Advanced Analytics

Health plans should partner with a vendor that can seamlessly aggregate data generated by gap letters, health risk assessments, and coding into one easy-to-use interface. By leveraging advanced analytics, your vendor should be able to uncover key trends and insights in your data, including average risk adjustment factor score, average RAF opportunity, member condition analysis, visit completion performance, and chronic condition recapture rate. These insights allow siloed teams to design a unified strategy for managing their populations and create better health and financial outcomes.

2. Data-Driven Interventions

With this analysis, your vendor should then be able to implement and execute an action plan that includes interventions at the member, provider, and plan levels. This could include coding, retrieval, health risk assessments, and submissions. For example, your vendor might recommend actively engaging patients with high RAF opportunities with visit completion programs or assisting providers with low recapture rates through member scheduling campaigns. Whatever technology platform you use should have a well-designed UX and UI so that it is simple for anyone in your organization to interact with your data and make real-time decisions.

3. Program Tracking

Reporting visibility and tracking are critical components of any risk adjustment solution. Your vendor should be able to translate and track complex data over time and understand how to communicate it effectively. To this end, Episource created a Risk Program Assessment, a curated action plan that assesses the current state of a health plan’s risk adjustment program to address the root causes behind what is working and what is not.

4. Compliance Focus

As the Centers for Medicare & Medicaid Services and the Office of Inspector General increasingly use sophisticated analytics to uncover instances of fraud, waste, and abuse, compliance should be a core component of any risk adjustment platform. It will be critical to partner with a vendor that can leverage NLP and data analytics to examine claims, charts, and supplemental data to surface high-risk hierarchical condition categories that could lead to compliance risk. Episource created our own Retrospective Compliance Cleanup service to accomplish just that.

The Future of Healthcare

As healthcare increasingly becomes more digital, the way patient data is collected, managed, and accessed will continue to change. Providing the tools necessary for your organization to keep pace with technological advancements will ensure sustained success in a world of value-based care. Healthcare delivery and risk adjustment are already challenging enough. Partnering with a vendor that seamlessly aggregates, analyzes, and acts on your data can lead to improved outcomes across the entire risk adjustment continuum.