Risk Adjustment

How to Evaluate Risk Analytics Software For Success

With the growing number of analytics tools available to support the risk adjustment process, that job should be getting easier. However, in the frequent conversations we’ve had with MAOs around the country, we’ve found that while they are capturing lots of data, they lack the time or resources to interpret it and draw appropriate conclusions to close their data gaps.

A successful risk analytics system should give you more than a dashboard full of data. It should take you from the starting line to the finish line, with a clear path to action based on accurate and relevant data and the right support when you need help.

For a solution that simplifies the risk adjustment process and gets you the reimbursements you deserve, start by asking the following questions.

Will your analytics system give you a complete understanding of your population?

In order to capture appropriate data, meet submission deadlines and maximize your reimbursements, you need a clear understanding of your population at all times: their health conditions and how their conditions impact their RAF scores. The right analytics tool gives you the power to filter through diagnoses and demographic data, audit specific populations and identify opportunities for RAF improvement. Additionally, it should be simple to use and understand. If it takes days or weeks of training to make sense of it, chances are it won’t be used effectively.

When looking at features, focus on those that provide the data that matters and make sure you can drill into member details so you have the information you need to evaluate:

  • Members with diagnosis codes that maximize reimbursement
  • Members with a diagnosis but few or no HCC codes
  • Members with no visits
  • Providers who are not participating (PNPs) or performing well
  • Clinical Suspects requiring a closer look to confirm diagnoses

Can you monitor your risk adjustment activity easily so you avoid surprises?

No MAO financial officer wants to learn their RAF score has taken a dramatic decline too late to fix it. It’s critical that you understand your program’s status on a weekly basis so you know how your programs are progressing and when you need to make adjustments.

A system that provides accurate and regular reporting will keep you up-to-date with a breakdown of eligible members for a specific DOS, their average RAF score, members with no HCCs or provider visits, recapture rate, and other valuable information to keep on top of progress . You’ll always have your recapture rates at your fingertips, be able to evaluate the quality of your audits and know your average RAF score in real time.

Will the system provide timely and actionable strategies for improving your results?

Many analytics software programs provide a lot of impressive dashboards that give you everything from predictive modeling to population health outcome analyses. What you do with that data is left up to you.

If you’re going to invest in a new system, you don’t want it to increase your existing workload. Look for a system that can provide advanced insights, recommend strategies to solve specific issues and generate appropriate workflows.

These workflows should be relevant to your specific projects and may include a chase list of members with HCC gaps who require home visits, a campaign to target providers who are not participating, or an appreciation program that encourages providers who are on top of their game.

What kind of support does the software supplier provide?

Having an intuitive software program that provides the right data at the right time with the right workflows will significantly reduce the challenges of risk adjustment. Having live support will take you several steps further in ensuring project success.

When considering your purchase and the value you receive, look for a supplier that provides a dedicated account manager who can help you manage your projects and find the most efficient ways to organize your charts, process attestations, close your gaps and meet your deadlines.

To learn more about how you can simplify your risk adjustment process and improve your financial performance, subscribe to our Innovation Hub, where every week you’ll find valuable articles, white papers, video presentations, news and webinars.


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