Know the Key Insights on Healthcare Risk Adjustment for the Year 2022
Around the US, every healthcare system is struggling with rising costs and uneven quality despite the hard work of well-intentioned, well-trained clinicians, payors, and health systems. Healthcare leaders and policymakers have tried countless incremental fixes—attacking fraud, reducing errors, enforcing practice guidelines, and making patients better ‘consumers,’ but none have had much impact. It’s time for a fundamentally new strategy - I absolutely believe this.
Healthcare delivery is gradually mutating! In a few years, the Medicare Advantage (MA) enrollees will outshine (the regular fee-for-service enrollees). Modern renditions of computer-assisted coding solutions have incorporated state-of-the-art artificial intelligence (AI) methods to enhance clinical documentation—charts, and notes, that identify which medical codes are relevant to a particular case.
In 2022, I had an opportunity to attend some conferences (below) as a ‘student’ of Risk Adjustment and met with outstanding thought leaders and change makers , and I owe a majority of my knowledge to them.
My Key Learning:
- Risk adjustment and value-based care (VBC) are the only viable future. We do not have any other options. It provides better value to the providers and better care to patients.
- A deep and synergistic collaboration between a payor, provider, and the Government is the key to the successful implementation and adoption of VBC.
- Adoption of VBC will start with primary care providers, however, without favourable economics for specialists, it will be difficult, if not impossible, to successfully implement VBC.
- Artificial intelligence, particularly, natural language processing (NLP) and machine learning (ML) will play a key role in Healthcare, especially now that the healthcare industry is facing a shortage of manpower. The market will emphasize user-friendly, evidence-based, technology-enabled approaches to improve healthcare delivery.
- The Centers for Medicare & Medicaid Service (CMS) is expected to publish the new Risk Adjustment Data Validation (RADV) rules on Feb. 1, 2023. These are expected to consider the recommendations from the Office of Inspector General (OIG) report. These rules will increase audit scrutiny. Any organization taking diagnoses over the phone using in-home assessments without obtaining any support for said diagnoses will be on watch.
- Eight of ten biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to federal audits. And four of five largest players have faced federal lawsuits alleging that efforts to over-diagnose their customers crossed the line into fraud.
- Prospective risk adjustment review is seeing a lot of growth and importance.
NLP & AI is extremely important for Hierarchical Condition Category (HCC) recapture, identifying missed and suspect conditions for accurate risk adjustment. Apart from being focused on innovating SaaS and API-based solutions, I understood that events, including RISE, HEDIS® & Quality Improvement Summit, AI in Healthcare Summit, Beckers Payer Issues Roundtable, and HLTH (pronounced ‘health’) bring like-minded people to discuss this daunting challenge and solutions.
I am super excited with RAAPID INC ’s AI-driven customer-centric solutions that are helping healthcare risk adjustment professionals streamline and automate risk adjustment coding tasks to ensure a complete retrospective and prospective approach supporting the transformation to value-based healthcare is well underway.
People Process & Technology - Out of these three I would straightforwardly choose People over anything first as, the Right people will bring the Right process to implement the Right technology - and that’s what RAAPID believes.
RAAPID is a completely integrated, AI-powered medical chart understanding & extracting engine that operates on any patient data, including free text and unstructured content, to capture the complete risk of the patients. RAAPID’s solutions include HCC Capture (Chart Review), and HCC Compass (Chart Audit).
In the coming year ahead - we are all geared up for more customer on-boarding while providing cutting-edge technology and solution support specifically in the payors and healthcare technology companies.
On top of our existing products that cater to retrospective risk adjustment, we will be launching new products in 2023 to support providers and payors in excelling at prospective risk adjustment. I am passionate and extremely excited to bring the desired leap in the healthcare risk adjustment industry as I continue working with the cutting-edge AI technologists at RAAPID while we grow manifold and continue learning.
Wishing you a Happy and Healthy New Year 2023. Stay tuned for more insights on Risk Adjustment.
RAAPID INC Devanshu Yadav Durai Ramachandiran Prabhu Srivastava Aditya Yadandla Priya Sisodiya Dan Pucci
Product Management, Passionate about User Experience Design, Product Strategy, Product Lifecycle Management, Product implementations, Agile product development, Team Mentor, Perennial learner
1yBeautifully summarised Chetan Parikh. The market truly needs innovative solutions in all 3 areas - recapture, capture and validation of risk. NLP and knowledge engineering based solutions are perfectly suited to fill that need.
One Step At A Time
1yThanks for sharing Chetan Parikh glad to to see learnings and super excited about upcoming products and features launch
Vice President - Strategy at RAAPID.AI | AI in Risk Adjustment
1yGreat Insights.