Risk Adjustment

Best Practices for Year-Round Analytics Reviews

Written By
Meleah Bridgeford
Director of Risk Adjustment, Payer Solutions

Year-round analytics are fundamental to a full, accurate reimbursement. Regularly studying member data and continuously adapting campaigns allows plans to maximize the efficacy of their risk adjustment programs. The success of this method lies in consistency. Though many would acknowledge commitment to risk adjustment from January through December isn’t most plans’ system, all MAOs can see a benefit over traditional methods.

Optimizing Your Year-Round Analytics Campaign


Always start early


It’s common to overlook the fact that your initial risk scores are based on dates of service from the first half of the year. Many plans wait until halfway through the calendar year to start examining those dates of services.

As an example, plans look at their 2019 data in July 2019 to plan their risk adjustment campaigns for the rest of the year. The problem is that the data for the first half of the year’s dates of service will be used by CMS for the start of payment year 2020. By not capturing HCCs earlier in the year, a plan’s cash flow may be affected by a longer wait for their full revenue from 2019 dates of service.

The theory behind year-round analytics centers around identifying members to target over the course of the entire year. The system would begin with in-home health assessments early in the year, and then move into provider queries and attestation, chart reviews and coding, and other campaigns as the year progresses. Proactively highlighting and planning your campaigns can lead to a more consistently accurate revenue forecast throughout the year.

For example, analytics could help highlight members that have HCC gaps that wouldn’t be filled throughout the year without an at-home visit, as certain members have historically demonstrated they will not visit their doctor later in the year. Proactively finding these members that require additional financial investment from your organization can help with accurate revenue forecasting throughout the year.


Deploy analytics-driven campaigns


Analytics allow you to examine members’ historical data and pinpoint those with uncoded conditions, focus on medication management, and perform population health management. This is meaningful in multiple ways especially if your members are underutilizing primary care services. For example, members who are going to the emergency department often but not seeing their primary care physician are incurring unexpected costs that aren’t reflected in their risk score. By highlighting these members earlier in the year, you can use targeted interventions and education to mitigate their higher cost utilization of services.

Provider queries can also be done using analytics to ensure you’re understanding providers’ notes. If a provider is frequently undetailed in patient files, you can educate them on how to properly make chart notes so coders can better document.

Analytics can also support chart retrieval and abstraction and provider attestation. Starting chart review earlier in the year can have several benefits. An early review allows your organization to get information filed before September sweeps, which will increase the first few monthly payments in the next payment year. Additionally, reviewing charts throughout the year will highlight outstanding gaps to continue to target based on a higher level of risk. These tasks to maximize gap closure can occur throughout the year and in conjunction with other programs.


Supplement your resources


Your plan may or may not have the personnel to gather the necessary data and run the appropriate analytics regularly. A reliable risk adjustment vendor can precisely calculate risk scores and recognize any issues that may be negatively affecting the plan. An established vendor will have their own database that can be used in conjunction with other resources, making the targeting and review processes more accurate and effective.

Reviewing your analytics year-round and designing campaigns to optimize HCC capture is going to be more critical as the new HCC model goes into effect and submissions transition completely to EDPS. Plans need to have updated records and accurate coding from recent encounters if they even want to maintain their current RAF. At Episource, we’re here to help you track and review your analytics throughout the year. Learn more about our risk adjustment solutions or talk to one of our experts today to discover how we can help optimize your year-round analytics program.


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