Risk adjustment

Major submission deadlines for Medicare Advantage (MA) and Affordable Care Act (ACA) risk adjustment programs are in the rearview mirror. We’re now entering a critical point in the annual risk adjustment activity cycle: The period where programs review and select new vendors ahead of the next high-intensity coding season.

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Risk adjustment is a complex but vital competency accountable care organizations (ACOs) must develop in order to succeed in CMS’s Medicare Shared Savings Program (MSSP). Without capturing a complete, accurate picture of member risk during the reporting year, ACOs risk jeopardizing their benchmark performance and care management effectiveness. However, many ACOs don’t have the internal expertise to implement a successful risk adjustment program.

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As patients, we’ve all felt the pain of trying to transfer medical records. Between the HIPAA release forms, wait times, forgotten requests, and antiquated transfer methods (faxes and CDs are still common methods in healthcare), the process of trying to give a new provider our health data is filled with friction and blindspots. This friction exists between organizations inside the healthcare system as well. Insurance plans struggle to obtain clinical data from providers, providers struggle to access plans’ more extensive member claims data, and healthcare vendors struggle to access data from both sides, even with the appropriate agreements in place.

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The U.S. healthcare system has a major problem—but it’s not what you might think. What People Think Is A Challenge In Healthcare When most people talk about how healthcare is broken, they focus on the outrageous cost of prescription drugs and medical devices. They talk about a lack of access to affordable healthcare and good doctors. They rant about rapidly rising insurance premiums and long wait times.

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NLP enhances healthcare risk adjustment coding. Payers validate unmatched codes efficiently, boosting accuracy. Implement an NLP-enabled Second Level Review.

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Without risk adjustment payments being conducted, the instability of the market will continue, and drastic rate increases for the future are imminent. See more.

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2018 HEDIS changes included new measures, early deadlines, and successful Ciox support. Looking ahead to 2019, Ciox aids in year-round quality data collection for smoother processes.

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