Risk optimization

Risk optimization is all about accuracy, quality, and a prospective view of risk and opportunity – rather than a retrospective one.

We understand the strategies necessary to optimize risk adjustment, while delivering additional value and better performance across your care management and quality programs.

Efficiency, integration and better overall performance:
Let us help you take control of your risk adjustment, care management and quality programs

The Baker Tilly solution framework enables you to build sustainable, constantly improving risk adjustment, care management and quality programs. We empower you with insights built upon your data, with advanced algorithms you own and can use to address your risk adjustment challenges individually or to improve performance across all of your risk adjustment, care management and quality programs.

Solution framework

  • Magnifying glass
    Powerful, flexible insights
  • Arrows
    Improve engagement activities
  • Folder
    Manage data
  • Graph
    Optimize performance

Organize & integrate member data

Successful member level data quality and integration capabilities are foundational to the business and clinical processes of today's health plan

Many health plans have yet to master the art and science of bringing their membership, claims, clinical, and consumer data assets together in a way that is efficient and effective. In addition to addressing core data management challenges, health plans also struggle with identifying, testing, proving value and, ultimately, using new types of data for risk adjustment and care management purposes.

Our business and technical teams work with our clients and their vendor partners, helping them dramatically improve the results of their data integration and management processes.

From basic member identity resolution across multiple lines of business, to data structures designed to support member behavior analysis and engagement, to complex algorithms to match claims and interaction data across provider and partner platforms – we know how to help our clients effectively integrate data from disparate sources and use it to deliver more value in critical downstream processes.

Magnifying glass
Powerful, flexible insights

Develop powerful, flexible insights

Advanced analytics capabilities are strategic assets that deliver value across all areas of risk adjustment, care management and quality programs

We find that many of our clients struggle with execution of an analytics strategy at the enterprise level, but even more so within specific business areas. Building, testing, deploying and continuously refreshing insights about individual members that will be both unique to your organization, provide competitive differentiation and be flexible enough to adapt with changing business or market needs, is no easy task.

The difference between high-performing proprietary insights and outsourced, generic analytics can mean millions of dollars in revenue and, more importantly, tremendous lost opportunity when it comes to identifying the care needs and quality gaps important to your population and provider partners.

We help our clients prioritize and deploy proprietary models into their existing internal and vendor processes. As a result, our clients own, understand and can evolve these insights over time.

Helping our clients build processes that allow them to store, access and use these insights across all relevant programs and add monitoring capabilities that over an extended period of time enable a genuine "test, learn and refine" discipline to emerge.

Improve engagement activities

Orchestrate & improve performance of engagement activities

Effectively measuring, understanding and prioritizing your engagement activities across multiple initiatives, systems, and integration points is critical

Too often, health plans operate these functions independently, often creating frustration among providers and members – duplicating communication and requests for very similar activities multiple times throughout the year.

We work with our clients to help them quickly identify and address overlapping and potentially redundant activities, build a strategy for aligning to desired outcomes, and then apply an analytically driven approach to prioritize activities to achieve these outcomes. This may sound simple and straightforward, however, it is extremely challenging when processes and systems don't exist that integrate these often disparate functions.

We have experience helping our clients bring together existing internal and external processes and vendor relationships in a way that creates immediate value and delivers much greater ROI across potentially competing internal initiatives.

Manage data

Manage the quality and effectiveness of submission data

Tightly managed processes, integrated internal and external technologies and systems and a tremendous amount of careful governance are required to effectively run the data preparation and quality assurance aspects of your business

Whether you're documenting results of supplemental diagnoses activities, predicting future year opportunities or simply managing your membership and claims data for successful CMS acceptance, the same standards for rigor and quality apply.

Our rapid speed-to-value, client-driven approach to addressing these critical data-related challenges enables us to help you:

  • More effectively integrate and ensure operational-level quality of your most important data assets.
  • Understand and proactively address likely data quality and rejection issues before they become problematic.
  • Enable traceability (for audit purposes and for proactive issue identification) – at the business user level – from projected scores and opportunities to originating claims and membership data.
Optimize performance

Optimize program performance

Optimizing performance is more than just reporting and monitoring of your data quality, algorithms or vendor strategies

To achieve the maximum value from risk adjustment, care management and quality programs, health plans need to understand the opportunity for improvement at the individual and portfolio level. Even more important, health plans need the ability to simulate different strategies and likely outcomes, which will ultimately enable rapid and impactful course-correction.

Our team of health plan professionals can help you optimize many areas of your risk adjustment, care management and quality programs, including:

  • Vendor, score and process performance measurement and enhancement.
  • Longitudinal tracking and year-over-year comparisons and projections across a number of key dimensions.
  • Projected revenue opportunity at the portfolio and individual level.
  • Impact to revenue and financial performance based on changes to membership or competitive market position.
  • Impacts of clinical interventions and member receptiveness to outreach.
  • Improvements in quality measure scores.