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Risk Adjustment Compliance Recap: Best Practices for Avoiding Legal Action
Last week, Health Fidelity hosted a risk adjustment legal compliance webinar, “Risk Adjustment Compliance: Best Practices for Avoiding Legal Action.” I had the privilege of being joined by Health Fidelity VP of business development John Blevins as well as lawyers and healthcare legal experts Stephen Bittinger and John Lawrence of K&L Gates. The event itself […]
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Prioritizing Risk Capture Compliance with NLP
In the past few weeks, several new stories have broken around risk capture compliance issues, particularly when it comes to Medicare Advantage. Individual DOJ lawsuits around MA risk capture and government agencies like the OIG weighing in on MA policy itself have led to a barnstorm of op-eds. The crux of these stories, even the […]
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A 3% Annual RAF Improvement isn’t Nearly Enough.
Depending on the individual risk sharing arrangement, CMS will cap annual risk score improvement to a 3% RAF lift over the benchmark for a population. This can lead to a very common assumption, that 3% can be used as an obvious, un-nuanced goal for risk adjustment strategy each year. Unfortunately, this is incorrect. Fortunately, we’re […]
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Risk Adjustment and Revenue Cycle: Benefits and Steps to Success
Risk adjustment and revenue cycle are becoming increasingly intertwined as more providers take on larger risk contracts under value-based care, shifting the mix away from traditional fee-for-service. Historically, risk adjustment has been dominated by retrospective reviews for the purposes of supplemental submissions. However, the same cashflow pressures that drive focus on revenue cycle performance are […]
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What is HCC Coding in Risk Adjustment?
Despite the pivotal role value-based care has in healthcare in the United States, it’s often not well understood. In the same spirit in which we covered the basics of risk adjustment and two-sided risk, today we want to tackle HCC coding in risk adjustment. With any luck, you’ll come away with a better understanding of […]
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Concurrent EDPS and RAPS support from Lumanent
Health Fidelity is pleased to share that the Lumanent platform is fully prepared to offer concurrent EDPS and RAPS support, congruent with the CMS-HCC risk adjustment model transition.
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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 […]
