• 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 […]

  • 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 […]

  • An effective and essential risk adjustment strategy includes the prioritization of chronic condition recapture each year. The benefit of prioritizing your HCC recapture rate comes directly from the requirement of re-confirming a diagnosis and treating it. First, it ensures regular contact with clinicians to monitor and manage chronic conditions, overall improving the quality of care. […]

  • Our latest ebook, Pulling Both Levers: A Four-Year Analysis of Medicare Cost and Risk Adjustment, unpacks the critical, and often overlooked, importance of effective risk adjustment done in conjunction with medical expense reduction under value-based care.

  • As care patterns continue to shift, and we see new utilization patterns, the stability of capitation and the revenue insulation provided by thorough, effective risk adjustment are key to thriving during uncertain times.

  • Implementing a post-encounter coding review is an effective way to ensure complete and accurate capture of all 2020 risk adjustable conditions - without burdening clinical teams - while informing care and stabilizing revenue. Finding and closing these gaps today, with fee-for-service revenues having bottomed out and many provider organizations in a precarious financial position, is especially critical.

  • Robin Lloyd, HF Chief Commercial Officer, envisions the longer-term impact on healthcare delivery, policy, and technology following the coronavirus pandemic.

  • 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.

  • In mid-December, the Health and Human Services Office of the Inspector General (HHS-OIG) announced that an investigation into Medicare Advantage organizations (MAO) had found $6.7 billion in potentially unsupported risk adjustment payments, generated from chart review programs that overwhelmingly yielded additional diagnoses. The study further found that 99% of chart reviews resulted in added diagnoses—not […]

  • 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) […]

  • 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.

  • As providers take on increasing levels of risk, they need to understand the maturity of their processes, the workflows they need to optimize, and the levers they can pull to improve their risk adjustment outcomes. Find out how our risk capture maturity model can help you plan your improvement path forward.