Five Steps to Improve Your Risk Adjustment Process

Risk adjustment models are no longer confined to predicting costs for Medicare Advantage beneficiaries. Now they are more prevalent and widely adopted in various alternative payment models for value-based outcomes.

To calculate a per member per month (PMPM) capitated payment in managed Medicare plans, CMS uses a model that captures Hierarchical Condition Codes (HCCs) and assigns a Risk Adjustment Factor (RAF) to each patient. Different payment methodologies also use that model, for instance:

Blockchain moving into Healthcare

Blockchain is a rapidly growing industry buzzword, with applications from financial services to supply chain management. The technology’s inherent transparency, security, and reliability can solve several problems in the healthcare industry and can play a critical role in the digital transformation of healthcare in the United States. But before we go into some of the use cases, let’s first get acquainted with the underpinnings of this technology.

What is Blockchain?

Payer investments in community leading to healthier outcomes

According to the World Economic Forum, social and environmental risk factors account for 20% of health outcomes. Social determinants of health include the conditions of the places where people live, learn, work, and play. These conditions can affect a variety of health risks and outcomes. Unstable housing, low income, unsafe neighborhoods, and substandard education are some of the major factors that can influence patient health.

Apple has the Healthcare IT community FHIRed up!

Earlier this year, tech behemoth Apple announced it is launching a personal health record (PHR) feature with iOS 11.3. “App”tly named Health Records, the feature will aggregate existing patient-generated data in the Health app with data from a user's electronic medical record at a participating hospital.

Preparing for the next wave of Medicare Advantage enrollees

Created in 1965, Medicare is the federal health insurance program for people ages 65 and over, regardless of income, medical history, or health status. The program was expanded in 1972 to cover people under age 65 with permanent disabilities. The program helps to pay for many medical care services, including hospitalizations, physician visits, and prescription drugs, along with post-acute care, skilled nursing facility care, home health care, hospice care, and preventive services.