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Data Solutions & Analytics

Refining the Risk Adjustment Process

Project Overview
Project Overview

In the healthcare industry, risk adjustment data for CMS is a time-intensive process. Payers seek to maximize risk-adjusted premium payments and reconcile missing Supplemental Benefit Vendor data to adequately represent risk scores and prevent underpayment.

 

Our healthcare payer client engages third parties to manage supplemental benefits. In turn, these third parties use their own systems and processes to manage claims. Our client relied on a time-consuming method of risk adjustment using a spreadsheet and manual search to reconcile data for CMS. They needed a solution to save time and administrative effort in completing this process while ensuring accurate premium payments, staying in compliance with timely reporting of encounters, and proactively managing submission errors.

Results area
Results

Concord helped our client build the tools and processes necessary to save time and administrative effort in their risk adjustment process. First, our team created a data ingestion process to convert provider data to an acceptable CMS format from historical and ongoing data sources. This process provides reporting and generates EOBs for supplemental benefit vendor data. Once the data was in place, we developed a UI tool to extract value for business users. The UI reviews data from different providers and compiles it into one central location. Users can use the UI tool to match submissions and responses to a list of all records with errors provided by CMS. Correcting and re-sending data to CMS has never been easier.

 

With a new data ingestion process and UI tool in place, the business is able to continuously monitor and improve on a process that was once entirely manual. Our client was able to improve the completeness of Supplemental Benefit Vendor encounter submissions from 93% to 98.5% while reducing the overall cost of labor per year.

Risk Adjustment UI example showing rejected-open status claims from CMS data

 

The new system ultimately helps the business:

  • Share Supplemental Benefit Vendor encounters and provider diagnostic data to CMS
  • Stay in compliance with timely reporting
  • Encourage proactive management of submission errors

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