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What is two-sided healthcare risk?
Depending on your role at a health plan or risk bearing health system, you’re aware of value-based care (VBC) models. However, depending on the model itself (and sometimes within the same model of value-based care), there can be different variations of two-sided healthcare risk, also known as upside and downside. An organization’s level of engagement […]
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ACA Risk Adjustment: A Competitive Advantage
With the Biden administration re-opening the ACA exchange and the impacts of COVID-19 on employment through 2020 and beyond, we want to address the impact of ACA risk adjustment. The expanding healthcare landscape under the ACA and the continuous shift to value-based care means effective risk adjustment is often the difference between profitability and losses […]
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CMS Policy Update: RAPS and EDPS, Model Updates, and PY 2022 Risk Calculations
Last month, CMS released their final announcement for calendar year (CY) 2022. This is a follow up to the advanced notice we covered September, particularly around the RAPS and EDPS transition. Before we begin, I think it’s important to mention that while not every facet of every update from CMS impacts every organization the same […]
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The Opportunity and Benefits of the Clinical Review Specialist
A hallmark (and problem) of technology in healthcare has been the drive to automate processes and eliminate staff headcount to boost ROI. For risk adjustment operations in particular, this often results in an increased burden on physicians, asking them to learn and apply CPT, ICD-10, HCC, and any number of other codes alongside their primary […]
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What is Risk Adjustment in Healthcare?
Risk adjustment is a critical part of both the financial and clinical aspects of healthcare in the United States. Still, even many people working in healthcare don’t really understand what it is, why it’s important, or how it works. First, what is risk adjustment? Healthcare for approximately 110 million Americans is provided by the US […]
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Pre-Encounter Risk Adjustment: If You Try Sometimes, You Get What You Need
As the significance of provider risk adjustment grows, especially within the clinical workflow, finding the right solutions and adopting them in the right order is a critical part of success. Today, I want to discuss that, as well as exploring an unorthodox approach: using pre-encounter risk adjustment strategies that also supports care without burdening physicians […]
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HCC Recapture is Critical, HCC Recapture is Never Enough
Recently, we discussed the imperative of HCC recapture, especially in a year with encounter volumes heavily disrupted by COVID-19. However, HCC recapture is only a small part of the larger goal: discerning a complete and accurate risk profile of a covered population. With an accurate risk score, reimbursement can match the total cost of necessary […]
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CMS Policy Update on Encounter Data and Positive Risk Score Impact
On September 14th, CMS released part I of an advanced notice on risk adjustment for Medicare Advantage. The advanced notice itself has caused a stir despite being an update on the already in-progress transition toward the exclusive use of EDPS (encounter data processing system) for risk adjustment data submission, and the phasing out of RAPS […]
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Risk Adjustment and Telehealth Policy under COVID-19
Health Fidelity offers conclusions on the flurry of CDC and CMS telehealth policy updates around coding and risk adjustment practices under COVID-19
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Identifying Risk Adjustable Telehealth Patients in a Post COVID-19 World
Health Fidelity looked for a way to harness our expertise to assist our payer and provider partners provide continuity of care to their chronically ill patients. We decided to help providers identify and prioritize those patients who would be best served by telemedicine via a simple and quick suspecting report.
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The Opportunities of Technology-Enabled Risk-Sharing
Over 10% of the U.S. population is now covered by an accountable care organization (ACO), and the number of risk-adjusted lives is growing at roughly 15% to 20% each year. To date, risk adjustment has primarily consisted of payers retrospectively reconciling work done with payments owed. With the Medicare Access and CHIP Reauthorization Act (MACRA) […]
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Concurrent Coding Increases Claims Accuracy While Reflecting True Patient Disease Burden
Concurrent coding is an alternative audit process to correct documentation and coding errors that immediately follows the physician visit, before a claim is submitted for payment. Physicians are not coders, so concurrent coding finds billing oversights that physicians might overlook in the rush to complete electronic paperwork. Automating concurrent coding is available with the Lumanent Post-Encounter Review module from Health Fidelity.