- January 22, 2020
- Posted in Risk Adjustment
Over the past decade, health plans have successfully leveraged medical and pharmacy claims for risk adjustment, expanding to encounter data from electronic health records (EHR) and self-reported member assessment data, all in the hope of gaining more insight into the complete member profile.
Now consider the impact of adding clinical laboratory data into the mix. HIPAA compliant lab test values are current and contain vital information about the true nature of member health today and over time – as far back as 2 years. Not just a diagnosis, or a prescription, but a clear picture of the member’s health that will make risk adjustment analytics more precise, increasing reimbursement accuracy and helping your team meet financial business objectives.
The Key Factor to Better Risk Analysis: Clean, Standardized, and Enriched Clinical Lab Data
Unlike medical and pharmacy claims which have been long standardized to facilitate financial transactions (their true purpose!), lab records are a veritable mish mash of varying codes, values and information gaps. This makes them untenable for analytics and worse so at scale. Forms and formats used differ even within the same lab testing organization from facility to facility. A big data and health analytics platform, like prognosFACTOR™ transforms lab data “chaos” and makes it amenable to analytics by standardizing the formats, test naming, and results. In addition to enriching records with missing information. Sounds hard, because it is. No company has seriously tackled conforming lab data until Prognos. When you combine our track record and our clinical experience to develop clinical profiles based on specific criteria, that translates into a better understanding of member health and risk.
Efficiency Not Complexity: Lab Insights will Complement your Workflow and Complete your Risk Profile.
Working with data vendors can be involved and require support from IT, which can be time consuming and invite unnecessary complexity. With help from Prognos, team members can simply request that in-house staff pull a list of identified members and send rosters through secure email. Prognos then returns payer solutions including risk profiles, harmonized labs, and risk alerts. This information then allows payers to more accurately identify chronic disease in a timely manner and lower false positives, which leads to more targeted and effective member outreach, chart retrieval and review, and in-home assessments.
Ultimately, lab test insights improve clinical visibility which affects risk adjustment outcomes with dramatic improvements in coding and corresponding per-member-per-year. In fact, your operational workflows can be more efficient. Our clients have achieved a 3:1 ROI and higher.
Targeted, Efficient, and Accurate Risk Adjustment Execution
As is demonstrated above, lab data is a valuable asset for payers and providers when its full potential is realized. Lab data holds the capacity to help health plans gain insight into the true health status of their members. Additionally, lab data can also be incorporated into risk adjustment analytics through the normalization and harmonization process and helps plan chart reviews for the right members who have missing HCCs that can be identified.
Optima Successfully Incorporates Lab Data into their Risk Adjustment Program
Optima Health has risk-adjusted members who are part of Medicare Advantage, Medicaid, and ACA Exchange. The actuarial team was seeking best practices and complementary analytical partners to best manage their risk adjustment efforts. Specifically, Optima Health was looking for an analytics partner that leveraged insights from medical and pharmacy claims to identify members for retrospective review. In addition, the team recognized the value of looking at members further upstream in the process.
Dean Ratzlaff, Actuarial Director at Optima Health, states, “We chose Prognos because their lab data solutions deliver timely insight, is often used to diagnose medical conditions, and can add significant value for ongoing risk adjustment efforts. We wanted accurate HCC suspects for the optimal impact and lab data is an important component.”
Optima Health selected 50,000 small group members from its ACA membership who generated claims from the 2018 dates of service. With a simple, secure email, Optima Health was able to quickly send the member roster to the team at Prognos.
The Prognos Risk Alerts solution provided an incremental improvement to Optima Health’s risk adjustment results. With the 12 percent improvement in HCC identification and an average net revenue per HCC of $8,807 – the health plan gained reimbursement that would not have been identified without lab data.The ROI was 3.7 to 1, which satisfied Optima Health and a higher ROI is anticipated in the future as there will be more time to pull more charts.
Even though only more than half of the charts were pulled, the certified coders identified a 12% improvement in confirmed HCCS, which was over and above what was identified from medical claims.