Aug 13 2013 | Thought Leadership | By

Guest Blog: Managing Risk and Revenue in the Health Insurance Marketplace

In the coming months, payers will assume risk as a predicted seven million previously uninsured Americans enter the health care system.  Because of this, I’m pleased to offer guest commentary on Mike Long’s blog about the important and timely topic of Risk Adjustment and Revenue Management in the Health Insurance Marketplace.

Regulations on Risk Adjustment for the Health Insurance Marketplace were initially proposed on July 15, 2011.  In the three years since, the private sector has been busy innovating, finding ways to help payers manage risk and revenue in the Marketplace.  With the Department of Health and Human Services (HHS) estimating $45 billion in transfers from 2014 to 2017, prospectively assessing and managing risk can have a huge financial impact on payers, making the assistance of an experienced partner crucial as health care reform moves forward.

Adjusting risk in the Health Insurance Marketplace is based on the risk adjustment model for Medicare Advantage Plans.   As the operator of a 4.5 star-rated* Medicare Advantage plan, Lumeris is uniquely qualified to help payers manage risk and optimize revenue.  Based on our experience, we have developed a unique model enabling payers to understand their patient populations at an enterprise level, and then drill down to the individual patient level.

Several vendors are offering programs to maximize revenue through accurate documentation and coding as part of a prospective health assessment.  However, knowing the patients or populations of patients at risk or with gaps in care remains the bigger challenge and opportunity for payers and providers.  Using a formula similar to that of the Department of Health and Human Services and an aggregation of comprehensive clinical and claims data, Lumeris will create a patient risk score, which gives payers a prospective view of that patient’s risk and all high-risk patients in their population.  It also ranks patients in regard to risk adjustment reimbursement and offers a powerful tool for member outreach.  When offered to providers, patient worklists and patient care profiles, contained within Lumeris’ Accountable Delivery System Platform (ADSP)®, allow for proactive patient outreach, better coordinated and more cost-effective care.

Lumeris encourages payers to partner with physicians, giving them the tools and training they need to become true population health managers.  Because little or no health records exist on these soon-to-be-insured individuals, physicians must acquire comprehensive information on these new patients. They can do this through a patient-specific prospective health assessment.  These assessment programs provide the tools and education physicians need to accurately document and code, in great detail, high-risk patients. So what makes us different than all of the other vendors offering a prospective health assessment?  Our Enhanced Encounter program, when used in our Medicare Advantage Plans, has nearly a 70 percent completion rate driven primarily by our model, which centers on physician engagement and education.  Another benefit of the Enhanced Encounter program is that it preserves and enhances the physician and patient relationship, reinforcing a cost-effective PC model.

Another need for payers in the Marketplace is a partner to help with chart reviews and auditing.  Both can be complicated, but with an experienced partner, they are advantageous.  Voluntary chart reviews help prepare payers for the auditing process and correct possible coding errors, inaccuracies and incompletions identified through our ADSP. For the auditing process, the ADSP leverages collected data and also identifies needed charts for review.

These solutions are essential because risk adjustment and revenue management play a vital role in the financial sustainability of payers – facing a complex future in the Marketplace.

Lumeris has nearly 10 years of experience managing risk and optimizing revenue. We invite you to learn more or register for our webinar where we’ll be sharing more of what we’ve learned and how we can help payers thrive in this new environment.

*Plan performance STAR ratings are assessed each year and may change from one year to the next.

Not sure where to start? Talk to one of our advisors.