Do you know why more data can improve your bottom line? Risk adjustment and HEDIS programs generally require more data is essential. Otherwise, it will be impossible to service payers with fair and accurate reimbursements. As a result, there has been a growing backlash against the CMS’s announcement. The Centers for Medicare and Medicaid Services announced a move to encounter data. After 2022, they will only use encounter data to calculate Medicate Advantage risks. Insurers claim that this data is inaccurate and that it can hold up payment processing. Further, there are many operational challenges involved with gathering this data. Even the frequency of reporting can pose a serious burden to these companies.
Healthcare Data Analytics
Healthcare data analytics can improve the bottom line of your company. Medicare Advantage participants receive compensation from CMS via a capitated model. That means a flat fee is given to them per month per member, but the fee varies.
Since high-risk patients cost more, they are assigned a risk adjustment factor or RAF. The higher the RAF score, the more the provider is reimbursed. These patients would normally be less desirable because of their chronic health problems. However, this data analysis leads to an increased payout for taking them.
Precise clinical documentation is necessary for this reason, and it is a requirement. Risk score determinations use a complex model involving 70,000 ICD-10-CM codes. Seven thousand five hundred of these codes map to 79 HCC categories, and each of these has an assigned risk score.
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