Risk Adjustment

Our experience at the Medicare Risk Adjustment, Revenue Management, Stars and Quality

The Episource team traveled to San Diego for the 8th Medicare Risk Adjustment, Revenue Management, Stars Ratings and Quality Assurance — they definitely win for longest conference name!

We opened the conference with Rex Wallace from Rex Wallace Consulting, providing the attendees with an overview of the agenda, followed by a day packed with good content and excellent conversations.

One of our favorite sessions was “Achieving Synergies Between Quality, Risk and Revenue to Optimize Risk Scores, Integrate Chart” presented by Valerie Ogilbee and Matt Davis from the Health Plan. They did an excellent job of outlining the challenges they have faced as a plan, and the solutions they have implemented.


Our Director of Coding, Tim Buxton presented the session “The Value of Claims Data Validation for Accurate Risk Adjustment”, and per usual, he received a lot of questions after his very educational presentation.

Other great presentations included “A Triage Workflow for EDS Analysis Requests—Identifying the Submission Problem and Routing to the Best SMEs to Fix it” by Brent Zenobia from Cambia Health Solutions — great content, and great slides!— and “Building Enterprise Synergy Between Care Coordination and Risk Adjustment Activities” by Gabriel Medley from Gateway Health.


Issues Facing Plans Today

Conference attendees also shared their challenges and concerns with the group, some of the most relevant are:

  • Issues around behavioral health and how to deal with a segmented behavioral health network, and dealing with privacy issues. Gabriel Medley from Gateway Health offered the solution that when touching members it’s not necessarily about their dependency, plans can use certain set of questions that can act as a trigger to indicate potential issues.
  • Care management education. Nurses are driven by the model of care, and they are evaluated on performance, but sometimes they don’t know what risk adjustment means, why they collect the data, and how that helps the health plan and the member.
  • Invalidating data in the record. We designed our systems to never forget, but once the gap is in there but has no validity, how to get it out?

We closed the conference with the panel discussion “Hard to Improve Measures”, and after we got to enjoy the great weather San Diego has to offer.

Next up: Patrick Mascari and Claudia Gallardo are headed to the RISE Medicare Advantage Operational Summit in Chicago July 18-19, 2017. If you are planning to attend, don’t forget to stop by our booth and learn more about our financial analytics, RAPS/EDS reconciliation, and how to solve errors in your data before submission — all functionalities of epiEncounter. If you are experiencing issues with your data, don’t wait until the conference and feel free to give us a call.





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Presentation @ RISE VBC: Effective Collaboration Strategies Between Payer & Provider