Risk Adjustment Coding Needs Innovation in Modern Healthcare

After releasing new HCC coding guidelines, CMS has published the latest Medicare Advantage Rate announcements, sparking speculation around the impact on providers. These potential impacts include shifts in Medicare Advantage enrollment, questions around the effects of changing economic conditions, and increases in payments to Medicare Advantage plans.  All of this is unfolding at a time when government spending is under increased criticism – Medicare Advantage plans are known to cost the government more while providing less to patients [1]. These factors add up to a much more complex future of risk adjustment. 

Risk adjustment in its current state has faced deserved scrutiny. Models have been criticized for issues with accuracy, potential for overpayment, and an ever-increasing need for a higher quality of data validation. They've also been known to fall short for certain patient subpopulations.

Risk adjustment is primed for innovation, and providers will be smart to look for innovative vendor partners and solutions that help them address growing issues with risk adjustment coding.  Providers will need advanced options in navigating diverse demographic characteristics, social determinants of health, and changing rates from CMS and insurers. Solutions should leverage technology to develop improved care plans that meet the needs of both patients and providers while reducing costs and optimizing reimbursement. From clinically trained AI in medical coding to natural language processing (NLP), predictive analytics, and solutions that support audit readiness and enhanced compliance, there is a growing need for innovation in risk adjustment. I’m excited to see the wide range of healthcare stakeholders who are stepping up to fill this widening gap in the healthcare revenue cycle. 

As we move forward, I invite you to stay connected with 3Gen Consulting and the work we’re doing to provide comprehensive risk adjustment coding services and documentation to providers across the board. We’re excited for the solutions and results that we can bring to our healthcare provider partners and how we can help them provide continually improved care to the patient populations with which they are entrusted.