2021: The Year of Optimized Risk Adjustment 

Abby Bilyeu of Health Fidelity discusses optimized risk adjustment in 2021Calling 2020 disruptive to healthcare is an understatement. But 2021 offers some unique opportunities to become a year of optimized risk adjustment. With the signing of the American Rescue Plan Act of 2021, barriers and premiums for COBRA have been reduced or eliminated, there are new Medicaid expansion incentives, and the ACA marketplace has an off-calendar second opening. Similarly, the pent up demand for care from 2020’s focus on emergent and COVID cases is rebounding patient volumes. Finally, Medicare Advantage enrollment is soaring, with 2.4 million new enrollees YTD as of February 2021, a 9.9% increase, YOY, which also coincides with the MA 2020 DOS submission deadline extension, from February to August 2021.

Alongside these policy shifts, this year offers an opportunity to not just course correct but make 2021 a year of optimized risk adjustment.

The first step is to stabilize revenue and ensure gaps in 2019-2020 population RAF capture are closed. The deadline extension for Medicare from February 1st to August offers six months to perform multiple retrospective passes on submitted claims, finding and properly coding all captured conditions. Another key to revenue continuity is to focus on identifying missed and under-coded conditions that can return revenue now, for 2021 dates of service. Prospective programs like Lumanent Pre-Encounter Prep can be put to work as patient volumes rebound, capturing conditions that were missed in prior years and not just re-establishing prior RAF scores, but going deeper and improving them.

Once revenue is addressed, reducing unnecessary risk adjustment expense is important, especially in light of its standing under MLR rules for payers. Now more than ever, addressing unnecessary expense can solve parallel problems. For example, early on in 2020, it became clear for many organizations that manual record retrieval was a highly cost-prohibitive process that was prone to disruption from the pandemic. Turning to electronic, automated methods for clinical data acquisition makes sense for a number of reasons. Lumanent Connect is a fully automated record retrieval solution that applies to more than just risk-adjustment and can remove this systemic vulnerability while also reducing total costs. For organizations operating vital legacy technology that are lagging on upcoming interoperability mandates, Lumanent Connect can become a critical data access point, as well.

Similarly, compliance is yet another layer to consider when optimizing risk adjustment programs. Establishing a two-way coding workflow that ensures submitted claims are complete and accurate via redacting codes that lack clinical evidence will be integral for protecting against audits.

These are just a few ways to refine risk adjustment operations that can help bring your organization some relief from the last year. To really identify the holistic value of risk adjustment to your organization, we recommend performing an assessment, which allows you to build a roadmap to realize your full potential. Whether an organization is undertaking risk adjustment for the first time, or looking to reinvigorate their process, knowing just where to begin can be a challenge. Many of the steps can be interdependent, others may be contradictory in the wrong order, while others are force multipliers, picking up fast revenue to self-fund the initiatives.

Those exact challenges, that sense of “where to even begin” is precisely why we developed the Lumanent Risk Adjustment Value Assessment. It is a comprehensive technical evaluation and consultation. It is designed so it reveals the full value an organization can realize through effective, technology-enabled, risk adjustment. Each organization’s Risk Adjustment Value Assessment is a customized, data-driven report. It details which of your population segments, provider networks, and condition categories have the most opportunity—enabling targeting prioritization that yields a significant increase in outcomes over traditional methods.