Risk Adjustment & The Health Plan-Provider Partnership

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Today’s health plans are becoming advocates for proactive care models—trailblazing new ways of monitoring and improving member outcomes. As part of this initiative, the health plan-provider relationship is being reframed as a true partnership designed to deliver the highest level of patient-member care.

At the forefront of proactive care models, is the quest to reduce gap closure time frames and therefore, reduce the time frame of managing addressable conditions—getting members the care they need, faster. In the past, medical claims and coder teams manually parsed through medical records and claims data. Then, they relied on hand-written notes, fax, and even mail to correspond with the providers. But today, technology has changed this workflow dramatically, so what used to take weeks is now done in 24-48 hours. Technology has also reduced the documentation burden on providers by integrating CDI alerts and queries into their already existing electronic medical record (EMR) workflows.

Beyond the speed of information exchange, the data is leveraged using AI machine learning models to identify and predict member conditions, and notify providers on the next-best action. This thorough and timely exchange of data between health plans and providers pre-identifies gaps so members are getting care before a condition occurs while providing risk adjustment teams the documentation needed for CMS submission and timely reimbursements—both necessary components in controlling member premiums.

These advances in technology are benefiting the entire healthcare ecosystem—from health plans and providers to patients and members. Support your providers with the technology they need and together, you can improve risk scores, HCC value, Star Ratings, and member outcomes.

*Advantasure has flexible options for provider engagement to suite your business needs—including electronic, in-person support, and hybrid models. 

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