The Optimized Risk Adjustment Solution in 2021

Risk Adjustment (RA) is a statistical approach that considers health coverage subscribers’ underlying health conditions and healthcare costs while analyzing healthcare outcomes or expenses. Risk Adjustment Solutions help in ensuring compliance, precise compensation for beneficiaries' risk costs.

The COVID-19 pandemic levied a burden on the whole healthcare industry, particularly for the Risk Adjustment. The upheaval caused by the pandemic resulted in negative repercussions, including declines in preventative interactions such as yearly health and wellbeing checkups. There are some positive outcomes as well, such as the expansion of telehealth adoption among providers.

However, the year 2021 has shown a distinct potential to become a year of optimized risk adjustment. With the implementation of the American Rescue Plan Act of 2021, Consolidated Omnibus Budget Reconciliation Act (COBRA)  constraints and rates have been decreased and some are even removed. The legislation modifies various healthcare insurance programs to broaden Medicaid subsidy-eligibility and enhance government financial assistance for insurance plans while permitting the Affordable Care Act (ACA) exchange an off-calendar second opportunity to open.

Medicare Advantage (MA) registration is surging, with 2.4 million new subscribers, a 9.9 percent increase year on year, which further overlaps with the MA 2020 dates of service (DOS) filing closing date extension. The first objective is to regulate income and guarantee no gaps in the 2019-2020 population RAF. Another way to income continuity is to work on detecting overlooked and under-coded variables that might yield funding soon, for 2021 dates of service (DOS). Speculative solutions, such as Lumanent Pre-Encounter Prep, a National Language Processing (NLP) powered advanced Risk Adjustment Model, can be used when patient numbers increase, detecting conditions overlooked in previous years and not focusing solely on old RAF scores, but drilling down and increasing them.

Next, minimizing excessive risk adjustment expenditure is critical, especially given its position under MLR guidelines for payers. Optimize the efficiency and productivity of the internal coding workforce using Lumanent Retrospective Review. With a modular application suite, precise risk collection is possible. Luminant Connect is a completely automated data retrieving solution that refers to risk adjustment and can abolish this persistent risk while lowering spending.

Lastly, Medicaid Accountable Organizations (MAOs) must continue to monitor their risk adjustment procedures to ensure precise diagnostic data submission. Conduct targeted Hierarchical Condition Category (HCC Coding) evaluations for diseases that are prone to documentation inaccuracies.

The Risk Adjustment Value Assessment for each company is a unique statistics analysis. It identifies which market segments, provider groups, and disease classifications have the most potential, allowing for targeting priority that leads to a considerable improvement in outcome measures over conventional methods.