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Five Questions to Ask Your Next Risk Adjustment Partner

Published April 11, 2016 11:34 AM by Monique Barrett

[Editor's note: This post was originally written by Steve Whitehurst, CEO, Health Fidelity.]

As the availability of healthcare data continues to grow, many new technologies for risk adjustment are entering the market. When thinking about adopting a new risk adjustment solution, conduct a realistic self-evaluation in addition to also considering the support capabilities and workflow expertise of potential partners.

It's important to understand your own risk adjustment organization's readiness in order to determine the best external approach for your needs. In particular, a look at your overall performance, operations and infrastructure is vital to understand which partners will best fit your team's characteristics. You should have a full understanding of where your current risk scores are, outstanding opportunities, staffing levels, data acquisition processes, etc., to get a baseline of your overall maturity and sophistication. A reputable partner will have expertise and processes to help with this step. 

Once you have a good understanding of your status quo, it will be easier to consider where outside support is warranted. Most vendors love to pontificate on their solution, so we recommend you probe on their support, industry expertise and overall workflow adaptability in order to ascertain their overall fit with your operations.

Here are a five key areas to explore:       

  1. What are the improvement opportunities present in my organization? This involves not only the quantification of risk capture potential, but also an understanding of where in the risk adjustment ecosystem the opportunities exist. This allows for meaningful prioritization of the opportunities.
  2. What is the best method of improvement to address these opportunities? Retrospective review, prospective campaigns, provider education, billing staff education, member outreach, etc.?. Depending on the type of opportunities that exist, the appropriate method for improvement may vary. This is critical to maximizing the ROI.
  3. Is my organization ready to implement the proposed methods? If not, what are the gaps and how can I close them? The best methods will not work if there aren't enough coding resources or if the appropriate data isn't available. Together with the solutions partner, the readiness gaps need to be addressed before moving forward. A vendor with the best interest of the customer will not want to implement a solution without a readiness check.
  4. What is a reasonable timeframe in which we can expect to see results? Organizations can often have unrealistic expectations on how long the newly implemented solution will take to demonstrate performance improvements. Establishing measurable goals with specific timelines will help to attribute tangible ROI of the solution for leadership while maintaining engagement from key stakeholders and users.
  5. What processes will be in place to ensure improvements are continuously sustained? The biggest value of a technology-enabled solution is scalability. But if implemented without sustainable processes, improvement gains will be short-term, or your reliance on partner services will continue to incur costs. A sustainability strategy aligned with your organizational needs is essential.

Technology is only as good as the user. In a world as complex as risk adjustment, it is even more critical technology solutions are deployed to fit the specific needs of its stakeholders. When considering a new solution, organizations should ensure a potential partner's people and processes, in addition to the technology, are well-aligned with your strategy.

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