The Risky Business of Risk Adjustment Coding and Auditing

Posted in Payer Solutions

The world of risk adjustment is tricky – but critical to ensuring payers are fairly compensated for covering patients who are more likely to incur high healthcare costs. With risk adjustment, government programs such as Medicare and Medicaid will adjust the revenue provided to a health plan/payer based on the health of those covered.   …

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Natural Language Processing in Risk Adjustment Coding – It’s Not Just for Over-Reads

Posted in Healthcare Technology, Payer Solutions

Risk Adjustment programs are here to stay as we move into a value-based world. With reimbursement for health plans and providers tied to these programs, ensuring they are lean, efficient, and providing ROI is a top priority. With that said, Risk Adjustment coding is no easy process with all the unstructured content found in electronic …

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Payers Under Fire – Meeting FHIR Deadlines

Posted in Payer Solutions

As if 2020 wasn’t overwhelming enough for payers who are battling a global pandemic while navigating all the many changes it brings to policies and reimbursement – there’s also a mad dash underway to meet the deadline for Fast Healthcare Interoperability Resources (FHIR) exchange format standards which go into effect on July 1, 2021. This …

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Is Technology the Remedy for HEDIS Headaches?

Posted in Healthcare Technology, Payer Solutions

Payers and healthcare providers alike are in the constant pursuit of the triple aim in healthcare – including better quality, greater value, and improved patient satisfaction – as the shift to value-based care continues. For every health plan on the market, it’s critical to review and evaluate quality performance on a regular basis to ensure …

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The Six Most Important Changes Coming to Medicare Advantage Plans in 2021

Posted in Payer Solutions

Enrollment in Medicare Advantage (MA) Plans continues to climb each year. In fact, Medicare Advantage enrollment has doubled over the last decade. As the program takes on its increasing share of Medicare beneficiaries, staying abreast of changes and developments to the program remains more important than ever. Next year’s changes to Medicare Advantage are both …

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Are You RADV Audit Ready? Three Strategies to Get You There

Posted in Payer Solutions

The Centers for Medicare and Medicaid Services (CMS) recently announced plans to ramp up its risk adjustment data validation (RADV) audit program in 2020 based on a recent study by the Office of Inspector General (OIG), which found potential issues related to Medicare Advantage Organizations (MAOs) using chart reviews to inappropriately increase risk adjusted payments. …

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EHR Access for Payers? How (and When!) to Cooperate

Posted in Payer Solutions

In healthcare, safeguarding patients’ protected health information (PHI) is one of the most carefully followed rules, second only to behind “First, Do No Harm.” Hospitals, physician practices and providers understand their obligation to protect patients’ privacy at all costs. Much like any industry, the digitalization of health information has complicated the issues of privacy and …

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