![]() Increasing capture and reducing risk through technology To accurately capture risk and associated compensation, health plans have traditionally relied on laborious manual chart reviews performed by highly trained and expensive coding and clinical staff. Those 26 million enrollees account for 42% of the total Medicare population, and $343 billion (or 46%) of total federal Medicare spending net of premiums. In 2021, 26 million Americans were enrolled in Medicare Advantage plans, double the number in 2012, according to the Kaiser Family Foundation. Risk adjustment has taken on greater importance in recent years as enrollment in value-based care plans such as Medicare Advantage has surged. Related: Medicare Advantage Enrollment Trend: The “Up” Continues In 2020, the Medicare Payment Advisory Commission estimated that the risk scores for beneficiaries in Medicare Advantage were about 9.5% higher than what they would have been for a similar beneficiary in traditional Medicare, resulting in about $12 billion in excess payments to plans. Department of Justice filed a lawsuit against Buffalo-based Independent Health, a Medicare Advantage insurer, accusing it and a subsidiary of bilking the federal government out of millions of dollars over the course of nearly a decade by fraudulently adjusting risk scores to make members appear sicker than they were. Value is a risky business Risk adjustment has also generated controversy. For health plans, effectiveness in budgeting for value-based care arrangements heavily depends on accurately assessing risk at the patient and population levels. The capture of accepted risk factors requires a complete and accurate picture of a patient’s health, which can be challenging because critical details are often buried within unstructured text in the patient’s electronic health records (EHRs). ![]() The underlying risk adjustment scores provide health plans with a means of offsetting the higher cost of care for these patients based on the underlying conditions that increase their overall health risk. However, the cost of care can vary widely depending on a patient’s overall health. Value-based care programs, such as Medicare Advantage, reward health plans for collaborating with providers to help patients access quality care and achieve better outcomes. The more elevated a patient’s disease risk, the greater the payment to health plans and providers, which makes accurate risk capture an important component. Risk adjustment is necessary to ensure that health plans receive appropriate compensation for assuming responsibility for high-risk patients, and providers are compensated for accurately documenting and reporting patients’ conditions and treatment plans. The key to successful risk adjustment is to accurately identify patients’ full disease burden with substantiated data and documentation. Health plans attempt to offset the higher costs associated with members that have chronic health conditions. Risk adjustment is a process used to appropriately compensate health plans and providers under value-based models. It is within these frantic, mouse-clicked page-turns that the promise of value-based care is born - or extinguished. In other words, if eight different people need to analyze the information in a patient’s chart, the chart is reviewed eight times. With chart reviews, all of these purposes are served individually. healthcare system produces billions of pages of medical records each year, and the data contained in these records is needed by multiple stakeholders for a multitude of purposes, such as adverse events reporting, disease trending, population health management, revenue cycle management (including federal incentives and payment integrity), and research.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |