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Industry blog

Conquering Commercial Risk Adjustment

In theory, the commercial risk adjustment program was intended to help insurers taking on the heaviest load from the commercial health exchanges. Health insurers would submit risk scores for each enrolled patient to HHS. HHS would calculate an average risk score for each plan and then mandate cash transfers from healthier plans to sicker plans.

In practice, the reality is more complicated. Risk adjustment funds are flowing plentifully amongst plans. For 2015 benefit year, risk adjustment transfers averaged 10% of premiums in the individual market and 6% of premiums in the small group market. However, some plans feel they were unfairly penalized. Such complaints have compelled plans such as HealthyCT in Connecticut (-$13.4M) and Oscar Insurance of New York and New Jersey (-$33M) to drop out of the exchanges entirely.

These exits raise the question of whether risk adjustment funds are, indeed, going to the sickest plans, or if they are merely going to the plans that best understand the risk adjustment process. Risk adjustment is more art than science and plans who depend on limited claims data to evidence their risk scores may, indeed, ended up making their customers look healthier than they were. In contrast, plans who look at all their patients’ clinical data— all valid face-to-face encounter data— have a much better shot at proving their real risk. This is where Apixio comes in.

Apixio’s HCC Profiler for Commercial Risk provides more accurate, complete risk adjustment

Apixio has been helping insurers who cover Medicare Advantage (MA) for years. Apixio’s HCC Profiler tool ensures that MA risk score submissions are accurate, complete, and audit-proof. With our new commercial risk product, HCC Profiler for Commercial Risk, we will assist insurers who cover exchange plans, too.

HCC Profiler for Commercial Risk extracts clinical data on exchange enrollees from EHR or scanned patient charts, uses Apixio’s proprietary cognitive computing platform to rapidly scan the charts for risk-adjusting conditions, presents found conditions to expert coders for confirmation, and gives you final results— all within as little as four weeks.

Commercial risk adjustment is an unexpected challenge, but it’s not one that insurers with the proper documentation need fear. By looking at enrollees’ clinical data with technology like Apixio’s, it is very possible to get a full portrait of patients’ health in a reasonable timeframe. With such risk adjustment processes in place, insurers can go back to focusing on the part of the Affordable Care Act which really matters— delivering care to patients who had been left out of the healthcare system for so long.

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