Risk Adjustment

Risk Adjustment Analytics

Clearinghouse + EDI

Apply precision risk adjustment analytics specific to your market.

Apply Precision Risk Adjustment Analytics to Managed Medicaid, Affordable Care Act (ACA) Commercial, and Medicare Advantage Markets

As the healthcare industry continues its shift toward value-based care, health plans and payers are increasingly focused on avoiding administrative waste and promoting quality patient health outcomes. Precision risk adjustment analytics help health plans and payers reach these goals by providing four key benefits:1

  • Periodically confirming the presence of chronic illnesses and preexisting health conditions in members, thereby ensuring that plans are adequately funded to care for their members
  • Collating evidence, where it exists, to aid detection of unconfirmed, unsubmitted patient diagnoses—thereby ensuring that plans receive appropriate compensation
  • Leading to earlier, more appropriate treatment of affected members by earlier detection of their health conditions
  • Allowing precise, efficient targeting of risk adjustment interventions, thereby bringing health plans’ and healthcare providers’ attention to the right patients at the right time for the right reasons, while simultaneously minimizing attempts at interventions that have a low chance of success

Veradigm’s, Risk Adjustment Analytics solution(formerly Calcul8) delivers precise, advanced risk adjustment algorithms that are built from broad data sets for superior accuracy. Risk Adjustment Analytics enables health plans and payers to actively manage success with Managed Medicaid, Affordable Care Act (ACA) Commercial, and Medicare Advantage lines of business.

  • Provides the near real-time visibility needed to monitor and manage risk adjustment revenue against budgeted gap closures and Key Performance Indicators (KPIs)
  • Reports current, trending, and available opportunity risk scores on the Standard Risk Adjustment Analytics dashboards
  • Displays a population-level view of gap closure opportunities, detailing which gaps have been confirmed and which gaps remain open, on the standard Risk Adjustment Analytics dashboards
  • Supplies a big-picture overview of gap closure opportunities displayed by contract, risk adjustment factor, condition type, or confidence level using the Risk Adjustment Analytics Performance Summary Dashboard
  • Identifies and calibrates the confidence level for each gap closure opportunity
  • Prioritizes all possible gap closure opportunities using confidence-adjusted risk scores to recommend optimal intervention strategies to close each coding, documentation, and encounter gap worth pursuing
  • Saves money by identifying the most profitable gap closure opportunities, helping you avoid pursuit of low-yield interventions that may have little or no impact on risk scores

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Identify Optimal Intervention Strategies for Gap Closure Opportunities

Veradigm’s Risk Adjustment Analytics identifies gap closure opportunities through use of multiple predictive models based on the most current Risk Adjustment and Hierarchical Condition Category (HCC) methodology. It utilizes Big Data mining, clinical inferencing, and multiple predictive models to leverage a wide range of information. This enables it to create algorithms that consider more variables than those generally available to individual health plans. Big Data mining accesses.

  • Medical records
  • Lab results
  • Medical and pharmacy claims
  • Health assessments
  • Other “off the data grid” information

Risk Adjustment Analytics scores and calibrates the confidence level for each opportunity based on review of member and provider behavior patterns combined with the frequency, potency, and reliability of each data source. Risk Adjustment Analytics then uses confidence-adjusted risk scores to prioritize all possible gap closure opportunities.

Pursue the Right Member and the Right Provider with the Right Intervention at the Right Time

Accurate diagnostic coding is critical for both health plans and patients. For patients, accurate diagnoses are essential if they are to receive the care their conditions require, the care needed to prevent disease, lessen their progression, and stave off complications. For plans, missing or late diagnoses can prevent acquisition of the funding required for patients’ required care.

Despite this, diagnostic coding errors are common. Studies show that:

  • ICD-10 coding in patient medical records can have error rates ranging from about 20% to 50%2
  • More than 40% of patients’ chronic conditions are never reported3
  • Even among claims displaying accurate, specific patient diagnoses, about 30% fail to pass the Centers for Medicare and Medicaid (CMS) validation process due to a lack of sufficient supporting documentation3

Veradigm’s Risk Adjustment Analytics enables you to detect these and other types of errors. With patented Dynamic Intervention Planning, then recommends optimal intervention strategies for efficiently closing each coding, documentation, and encounter gap worth pursuing.

  • Target gap closures to the right patient at the right time with Dynamic Intervention Planning
  • Improve the efficiency of your intervention roadmap by pairing the most effective gap identification methodology with the most efficient gap closure strategies
  • Avoid pursuit of low-yield interventions that may have little or no impact on risk scores
  • Make the greatest financial impact in the ACA Commercial, Medicare Advantage, and Medicaid markets

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Actively Manage Success with Veradigm’s Risk Adjustment Analytics

Risk Adjustment Analytics Financial Reporting Suite enables you to monitor how well you are performing, helping risk-bearing entities to navigate the complexity of financial reporting. Risk Adjustment Analytics Financial Reporting Suite has the capacity to:

  • Predict Medicare Advantage Mid-Year Risk Adjustment or Final-Year Risk Adjustment impact
  • Use the ACA Commercial Modeler to calculate the Risk Adjustment Factor (RAF) Points, HCCs, or Condition Types needed to achieve budget and the optimal intervention type, level, and timing with which to get there
  • Monetize ACA Gap Closures as contributions to year-end risk transfer payments
  • Project the impact of revenue and risk scores for each individual contract

Veradigm’s Risk Adjustment Analytics can help you to stop wasting money and increase your financial reimbursement in all lines of business.

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  1. Wrathall J, Belnap T. Reducing Health Care Costs Through Patient Targeting: Risk Adjustment Modeling to Predict Patients Remaining High Cost. EGEMS (Wash DC). April 20, 2017;5(2):4. doi:10.13063/2327-9214.1279.
  2. Weed K. Why Are My RAF Scores Low? RCxRules. Updated August 20, 2019. Accessed April 5, 2022, https://www.rcxrules.com/blog/why-are-my-raf-scores-low.
  3. Cassano HJ. Factor HCC with a Two-pronged Approach to Risk Adjustmant. Advancing the Business of Healthcare (AAPC). Updated August 1, 2012. Accessed April 5, 2022, https://www.aapc.com/blog/24215-factor-hcc-with-a-two-pronged-approach-to-risk-adjustment/.

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