Gorman Health Group | Risk Adjustment – Exchange
16929
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Risk Adjustment

Efficient, Clinically Effective, and Compliant

As premiums continue to be reduced, health plan and capitated medical groups must have plans in place that ensure an accurate RAF score, meaning you must not only recapture your members’ persistent conditions, but find new clinical conditions as they appear.  Plus, many organizations struggle with creating accurate premium projections that support sound strategic planning.  In many cases, the very foundation of an organization’s risk adjustment program is missing critical elements, such as data flow mapping and coding policies that hold your varied risk adjustment vendors’ services and deliverables to a higher standard.  As CMS expectations regarding risk adjustment continue to evolve, health plan, ACOs, and capitated health systems must design and flawlessly implement a strategic, mixed model that incorporates a meaningful percentage of retrospective, concurrent, and prospective initiatives, plus drives data integration with care management.

 

Gorman Health Group supports our clients in evaluating the efficiency, compliance, and strategic value of their risk adjustment programs from start to finish, and helps ensure that the procedures for capturing, processing and submitting risk adjustment data to CMS are accurate, timely, and complete.  Whether you rely on multiple vendors or a largely internal team, GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you’re keeping pace with CMS expectations in both compliance and health care outcomes.  Let’s make certain you are ready for that RADV audit when CMS calls.

 

Remember, CMS is conducting a second code analysis on prospective assessments — perhaps you should be too, to ensure those codes find their way into the member’s plan of treatment.

 

Services include:

  • Risk mitigation
    • RADV readiness plan and facilitation with CMS
    • Second code analysis
    • Data point and integration audits
    • Best in class operations manual

 

  • Strategic planning
  • Determine the meaningful percentage of retrospective, concurrent, and prospective initiatives
  • Driving data integration across Stars, HEDIS, and care management
  • Accuracy assessment in forecasting and reporting
  • Model  readiness check (and new CMS or Medicaid model integration)
  • Policies development and adherence testing
  • Coding accuracy analysis for retrospective and prospective medical records
  • Logic, analytics, and reporting assessment
  • Vendor selection support
  • Vendor implementation support
  • Vendor auditing and oversight
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