在每个历年的年底, billions of dollars are transferred between health plans that participate in state-based Health Insurance Marketplaces, 哪些公司提供符合平价医疗法案(ACA)的计划. 这些美元, 通常称为风险调整转移支付(ratp), 到2022年,全国的收入将超过180亿美元, 相当于ACA计划总保费的10%.1
The ACA risk adjustment program aims to mitigate risk for plans by redistributing funds (through RATPs) from plans with healthier enrollees to those with sicker enrollees. 它被实现了, 在某种程度上, to encourage plan participation in the Health Insurance Marketplaces and attempt to create a financially equitable environment for all plans. However, the program and the RATPs have become a strategic factor of the economics for ACA plans.
RATP is a zero-sum game, so there will also be winners and losers each year. As the risk adjustment dollars continue to trend higher year over year—both in absolute terms and as a percentage of premium—a health plan’s performance in the ACA risk adjustment program is becoming increasingly tied to its overall success. 糟糕的表现可能会造成严重后果, as evident by the challenges faced by two notable ACA plans that faced nearly $2.到2022年,ratp将达到70亿美元.2 This level of RATP is extremely hard to account for and would leave a deficit in RATPs. Such a deficit would have a material negative impact on the ACA program.
2022年计划面临的挑战, 以及宏观RATP趋势, should be a wake-up call for all health plans that participate in the ACA risk adjustment program. It is critical that health plans optimize their risk adjustment processes to ensure successful outcomes and gain a competitive edge over the market.
Below are several strategies that plans can use to excel in the ACA risk adjustment program.
成功的关键
1. 投资于高级分析和报告.
- 稳健的数据集成系统: 只有通过综合数据才能获得全面的患者视图. Ensure your systems can aggregate data from different sources—like electronic health records (EHRs), 卫生信息交流(HIEs), 还有药房记录,以便全面了解病人的健康状况.
- 数据验证: 定期搜索数据中的异常情况. 一致性验证可以识别和纠正错误, 确保风险评分真实反映患者健康状况. A proactive approach to data validation and reconciliation can offer both accuracy and peace of mind.
- 持续监察及报告: 定期监控你的风险调整过程和结果. This not only ensures compliance but also helps identify areas for improvement.
- 错误解决协议: Have a clear strategy in place to address discrepancies when they arise.
2. 让你的会员和供应商参与进来.
- 易于使用的会员门户: Engaged members are likely to offer better data and be proactive about their health. 首先要有一个简单的交互式消费者工具. User-friendly platforms can encourage members to take an active role in tracking and managing their health.
- 及时、相关的沟通: Automated reminders for regular health checks can increase data points and ensure up-to-date health information.
- 供应商定期培训: 见多识广的提供者可以成为关键的盟友. Keep providers informed and updated about documentation requirements. Since the completeness and accuracy of clinical data are crucial for risk adjustment, 培训可以显著减少差异和错误.
- 文档的标准: Regular provider seminars or workshops can clarify documentation expectations, 导致更准确的数据提交.
- 反馈机制: Allow providers to offer feedback on the risk adjustment process, ensuring continuous improvement.
3. 确保遵从性
保持监管的完整性是不容谈判的. Staying up to date on evolving ACA and associated guidelines can prevent potential setbacks and position your organization to take advantage of any new opportunities.
- 定期审计: Periodic checks will ensure processes align with regulatory demands and reduce the risk of penalties.
- 培训: Keep your team updated on compliance requirements to ensure consistent adherence. It is also important that any process or program changes are promptly communicated and implemented across the organization.
- 供应商监督: A robust vendor oversight mechanism ensures that third-party engagements do not compromise the risk adjustment process. Vendor oversight should have strong governance that includes clear and objective contractual terms, 性能指标和标准, 并与每个供应商定期沟通.
- 定义良好的角色和职责: Establishing clarity in roles and responsibilities is foundational to the success of the risk adjustment process. 通过创建定义良好的角色和职责, organizations can ensure that every aspect of the risk adjustment process is handled efficiently. 它减少了歧义, 增强合作, and ensures that each step in the process is executed by those best equipped to handle it.
4. 了解你现有的和计划的会员.
用最简单的话来说, success in the risk adjustment program is a function of obtaining (or retaining) projected membership targets, understanding the care requirements or risks of your ACA population, and effectively managing the care delivery for your ACA population. To do this, it is important to evaluate members’ needs both retrospectively and prospectively.
- 回顾评论: Dive deep into past records to ensure no condition is overlooked, capturing any missed revenue.
- 未来的策略: 通过预测未来的健康事件, 你可以更好地分配资源和规划护理干预措施.
赢得零和游戏
Achieving success in the ACA risk adjustment program is a delicate balancing act that requires meticulous attention to detail, 有远见的, 一致的监督, 无休止的协调. By focusing on these areas of improvement and maintaining a proactive approach, payers can ensure their operations are both efficient and compliant.
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编辑:马特·马斯林
2. http://www.cms.gov/files/document/unpaid-by2022-ra-charges-memo-10-26pdf-508-compliant.pdf
出版于2024年2月5日