Risk adjustment is a critical process that involves providers, payers, and healthcare administrators in the value-based care landscape, and plays an irreplaceable role in ensuring equitable healthcare delivery and reimbursement.
Given the complexity of risk adjustment, healthcare teams need modern software solutions to manage patient data efficiently and calculate risk scores at scale. In this guide, we’ll shed light on frequently asked questions in addition to providing a list of the best software vendors on the market. Here is a quick overview:
Whether you are new to risk adjustment or ready to choose a vendor, this guide will show you how technology is revolutionizing healthcare risk management and optimizing patient outcomes and financial sustainability.
Risk adjustment analytics provide a statistical method to predict a patient group’s likelihood of using healthcare services and the associated costs. The method equates a patient’s health status to a number, called a risk score, to predict healthcare costs.
Providers submit diagnosis codes on claims data that define a patient’s risk score. Payers then rely on accurate risk adjustment to build health insurance plans. This payer-provider collaboration is essential for maintaining cost and quality standards across individual patient groups. In turn, effective collaboration ensures that patients receive appropriate compensation while supporting the equitable and efficient distribution of healthcare services.
Risk adjustment software is a specialized tool used to analyze patient data and perform risk score calculations.
In the past, traditional healthcare systems relied on paper-based workflows to finalize quality programs. This forced health plan quality and risk teams into a cycle of “chart-chasing” to capture evidence and verify risk and quality data, yielding decreased efficiency, underwhelming performance, and stifled communication.
Cloud-based and integrated risk adjustment software acts as the solution to this problem by reinventing the paper-based workflow and reporting structure. The software enables providers to identify and document suspected diagnoses at the point of care. Furthermore, networks can increase transparency and close risk gaps. This can lead to higher reimbursement and reinvestment into better patient care.
Fully functional risk adjustment software leverages several features to provide cross-network, effective care. Here’s an overview of each:
Armed with these modern features, care teams can enhance patient care and operational efficiency without worrying about administrative burdens.
When providers embrace risk adjustment software, it can greatly simplify their workflows. Watch this video for a closer look:
As described in the video, the risk adjustment process is threefold — suspect, engage, and assess:
With the right software to support providers every step of the way, care teams can provide improved patient experiences and unlock increased savings from proactive resource allocation. This results in a win-win-win outcome for patients, payers, and providers.
To generate accurate cost predictions, providers must have access to a variety of data (inpatient, pharmacy, SDoH, etc.) at the point of care. This is where EHR-integrated risk adjustment software comes into play. When narrowing your software search, here are a few essential features to prioritize:
Study vendor reputation and compare their services to your immediate and long-term needs. For more information, consider scheduling personalized demos to see the software in action. Collaborate with your key stakeholders throughout the decision-making process so that everyone is on the same page, from software selection to implementation.
As a KLAS Featured IT Vendor, Arcadia simplifies risk coding and documentation to provide clear visibility across your entire network. Our comprehensive risk adjustment application library can help you unearth meaningful data points and drive healthier outcomes. Here’s an overview of each featured application:
Additionally, our HCC Risk Suspecting App aggregates data from multiple sources (claims, EHR, APIs, SDoH) and then enriches it with a proprietary risk-suspecting engine. The app integrates payer and EHR data into a single data asset, enabling diagnosis suspecting from notes, labs, orders, and vitals. Get a closer look in the video below:
Advantasure provides comprehensive and balanced risk adjustment solutions to achieve complete and compliant risk score accuracy. Their specific services include:
Advantasure recommends bundling its risk adjustment program with administrative and care management solutions to experience comprehensive success.
Advantmed offers end-to-end risk adjustment solutions with 98% coding accuracy to provide accurate risk profiles for enhanced results. Here’s an overview of its risk adjustment services:
With Advantmed, providers can access understandable, actionable analytics that improve Risk Adjustment Factor (RAF) scores to close documentation gaps and utilize prevention and predictive modeling.
Apixio is an AI-powered technology that increases risk adjustment accuracy and efficiency to decrease administrative time and cost. The platform’s risk adjustment coding and auditing solutions help teams scale chart review processes and capture complete pictures of patient population health. Apixio’s core risk adjustment services include:
Equipped with these features, Apixio eases the coding workload and decreases the chart review process time without sacrificing coding accuracy.
Change Healthcare’s comprehensive risk adjustment platform, Risk View, helps healthcare insurers understand risk score trends and opportunities, optimize financial results, and identify targets for appropriate risk-adjusted reimbursement. Its risk adjustment solutions include:
Change Healthcare offers comprehensive reports to inform strategic planning based on end-of-year and end-of-project metrics. Models used AI, big data, and chart selection to assess and target appropriate members.
Coviti’s risk adjustment solutions ensure compliant, accurate compensation for member risk burdens. The platform provides advanced tools to optimize risk-associated revenue while maintaining transparency at every stage of the process with the following services:
Cotiviti’s extensive risk adjustment experience and deep subject matter expertise can help organizations keep tabs on their programs to enable accurate reimbursement from accurate documentation.
The Episource Clarity platform is an end-to-end solution for risk adjustment and quality initiatives built to deliver tangible outcomes for leading health plans and risk-bearing providers. The platform portal includes the following applications:
Intending to “provide clarity at every stage,” the Episource Clarity Platform supports care teams by identifying areas of opportunity, assessing program performance, and providing comprehensive compliance review.
Pareto’s risk adjustment solution, Pareto Hub, is a cloud-based data environment built by business experts that transforms and enriches raw, disparate data assets into business-ready analytics. The solution’s core capabilities include:
Pareto’s Data Management Platform enables data ingestion of all formats and types at scale with built-in governance mechanisms that maintain compliance and efficiency.
Accurate risk adjustment requires several moving parts to work simultaneously — data collection and analysis, standardization, predictive modeling, and continuous monitoring. A robust software solution can automate many of these processes resulting in enhanced collaboration, accurate reimbursement, and improved patient care.