Gorman Health Group | Healthcare Analytics & Risk Adjustment Solutions- Medicare
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HEALTHCARE ANALYTICS AND RISK ADJUSTMENT SOLUTIONS

Leveraging Analytics, Integrating Strategies, Maximizing Revenue

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. 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. 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.

Risk Adjustment Strategy, Operations and Oversight

A comprehensive, enterprise-wide strategy for risk adjustment will not only ensure accurate revenue capture, it will support your organization’s mission to provide quality care at an affordable cost. Designing integrated programs and processes for Risk Adjustment span across multiple functional areas within health plans, provider groups, ACOs and other health care delivery models. GHG continues to anticipate the regulatory changes for Risk Adjustment, working with our clients to proactively address shifts in payment models and build cross-functional teams to achieve maximum performance outcomes.

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Analytics, Data and Process Integration

Big Data is costly, distracting, overwhelming and paralyzing if not maximized. System and process interoperability and integration are keys to program alignment, oversight and evaluation. As the cost of providing healthcare services escalates, the need becomes greater to provide better information to both those that deliver and those that pay for care. Selecting the right partners and implementing the right tools to produce valuable and actionable data will allow clinicians and health plans to prioritize interventions, stratify the populations they are managing and identify those most at risk. Systems and data should not just integrate; they need to align in order to yield superior, reportable outcomes.

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Health IT Optimization and Innovation

The most successful health plans and delivery systems are those that diligently assess their processes and focus on the targeted implementation of existing and new technology. Whether you are stabilizing, addressing a specific problem area, or are ready to take your system and users to the next level, Gorman Health Group can bring experienced talent and proven methodologies to improve your optimization and adoption efforts. New technology is not always better, leveraging your existing investments to assess performance, value and current state for integration capabilities will determine the need for system and process upgrades. Guidance on industry trends in technology to drive revenue, reduce admin costs, improve quality and manage medical trends- all need to be incorporated into your technology strategies.

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Revenue Maximization

The revenue cycle is a critical component in improving cash flow, reducing costs, and providing quality care and service in the health care industry. Whether you are a health plan, medical center, foundation, ACO or IPA, you must address numerous handoffs and communications, exchanges of data, accuracy challenges, and regulatory requirements. Most finance departments lack the systems and processes necessary to manage financial performance under the Affordable Care Act and the shift to value over volume.

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