Platform implementation for national healthcare payer optimizes risk adjustment revenue
Case Study

Platform implementation for national healthcare payer optimizes risk adjustment revenue

Platform implementation for national healthcare payer optimizes risk adjustment revenue
Case Study

Platform implementation for national healthcare payer optimizes risk adjustment revenue

Client background

Global health insurer with more than 95 million customers across multiple lines of business.

The business challenge

Our national health plan client was attempting to optimize accurate risk adjustment revenue for its Affordable Care Act (ACA) population. Our client entered the ACA market in 2014 and had been leveraging third-party vendor analytics and operational support for the first three years post market launch. In year two, the analytics leadership team determined that there was likely significant revenue that was going unrealized with their current vended solution. Unable to independently validate the results of the vendor’s proprietary algorithms, the client made a strategic decision to bring critical analytics and opportunity identification functions in-house. With a strong set of hypotheses around additional revenue and cost savings associated with internally-generated efficiencies, the company engaged Baker Tilly to help them build an internal Risk Optimization capability and platform.

The Baker Tilly approach

In close collaboration with our client, Baker Tilly designed and built a solution to enable analytics and operations business users, without significant support from the IT organization, to effectively identify opportunities for additional accurate risk adjustment revenue and to automate existing manual processes to chase, code and close gaps on these opportunities. Specifically, the new solution delivered the following new internal capabilities:

  • Management and coordination of multiple predictive models to help identify and prioritize opportunities for coding accuracy improvements, missed HCCs and additional revenue
  • Stratification of risk adjustment opportunities according to the reliability and confidence of the predictive model and relative value of the projected HCC
  • Support for end to end workflow, including automated assignment of individual members to the best possible gap closure activity (in-home exam, chart retrieval, etc.) based on a variety of advanced analytics inputs
  • Integration of chart chase and coding vendor operational data for performance measurement and activity optimization
  • Flexibility to modify algorithms (CMS or proprietary algorithms) within the system to allow for scale and future potential changes to regulations or market dynamics
  • Centralized repository of all risk scores, all projected HCCs, and all opportunity scoring – month over month, for multiple years
  • Flexible, powerful business rules that can be adapted to meet virtually any risk management or adjustment need

The business impact

As a result of the functionality created during the first two phases of this engagement to build and deploy the client’s proprietary solution, they have realized the following benefits:

  • Improved accuracy of identifying and prioritizing opportunities for capturing missed revenue. At the close of Phase 1, program leadership was anticipating a 6% improvement in opportunity identification compared to the previous vended solution
  • Reduced manual processes
  • Improved reporting and analytic capabilities
  • Delivered a foundational data and analytics platform that can be further refined and leveraged for additional business purposes
  • Increased the speed of executing the end-to-end risk optimization process with the targeting of risk adjustment opportunities processing window alone down from a process that took weeks to one that runs in a day
  • Reduced the potential for errors that arise when executing tasks manually through workflow processing designed into the solution
  • Created the existence of a formal production process, protecting against data quality errors and potential audit issues
  • Integrated workflows across multiple teams
  • Allowed for the longitudinal storage of process results and key data elements
  • Productionalized reports showing detailed and aggregate member risk attributes and the resulting opportunities for revenue capture

For more information on this topic, or to learn how Baker Tilly specialists can help, contact our team.

Large multistate Blue Cross Blue Shield plan enables advanced consumer engagement insights for an improved member experience
Next up

Large multistate Blue Cross Blue Shield plan enables advanced consumer engagement insights for an improved member experience