Health Fidelity Launches Risk Analytics for ACA Risk Adjustment

Solution Optimizes Risk Adjustment Strategy for Plans Going into 2017 as Reinsurance and Risk Corridor Programs Drop Off

Health Fidelity, a company that develops innovative technologies for the value-based care era, today announced that their Risk Analytics solution will now also support risk adjustment for organizations participating in the ACA market. The solution, which was launched in March 2016 to support risk adjustment for Medicare Advantage plans and Medicare ACOs, helps risk-bearing healthcare organizations improve their financial outcomes by measuring business performance and by optimizing prospective risk capture.

“Plans that offer ACA products face significant financial uncertainty and many have reported worse-than-expected results. This problem will become even more acute as the reinsurance and risk corridor components of the ACA expire. This means that risk adjustment, the permanent component of the ACA, is critical to the financial viability of ACA lines of business,” said Steve Whitehurst, Chief Executive Officer of Health Fidelity.  “Plans remain in the dark about their risk adjustment transfer payments until the results are released the following year, when it’s too late to adjust strategy. Our Risk Analytics solution allows plans to continuously measure risk adjustment performance, estimate the potential impact to transfer payments throughout the year, and optimize risk adjustment efforts to ensure payments are commensurate to the population risk they bear.”


Risk adjustment opportunities.

Health Fidelity’s Risk Analytics solution helps organizations identify prospective risk adjustment opportunities in the form of suspected conditions that are neither documented nor submitted to governing entities. Its suite of reports and visualizations provides actionable insights that help inform prospective campaign strategies to optimize ROI. It is the only analytics solution available in the market that generates suspected conditions from unstructured clinical data in medical records by applying industry-leading natural language processing (NLP) technology. This technology identifies incremental opportunity that would otherwise be missed due to incompleteness or inaccuracy in claims data.


New ACA capabilities.

Using Risk Analytics, ACA plans will be able to better target prospective risk adjustment initiatives by stratifying opportunities in metal levels and age groups. Furthermore, plans will now have the ability to estimate the potential impact to transfer payments based on outstanding suspected conditions. Using customizable values that affect transfer payment estimates specific to each market, such as plan- and state-specific factors, plans will have better visibility into how their initiatives are impacting transfer payments.

“ACA plans need to ensure now that they have a solid risk adjustment strategy going into 2017,” said Whitehurst. “Setting up a comprehensive platform like Risk Analytics in 2016 will help organizations be prepared for when the safety net of reinsurance and risk corridors is no longer available.”


Risk Analytics for ACA, Medicare Advantage, and Medicare ACO is available now. To learn more, download our Risk Analytics data sheet.

Health Fidelity simplifies risk adjustment, offering risk-bearing organizations clear visibility into and control over the process. Through our NLP-powered solutions and expert advisory services, we uncover insights that enable better care plans and more complete revenue capture. The Lumanent® suite gives our partners the confidence to pursue and ability to succeed in risk-sharing arrangements across MA, ACA, Medicaid, and ACO programs.


Andrea Serra
(650) 727-3300