Commercial payers: Don't leave money on the table
To put more risk-based dollars in the bank, payers need to master a new level of gathering and reporting on not just claims data, but clinical data as well.
It’s a brave new world of risk management out there, and commercial payers-traditionally the masters of risk-have an ever changing game to learn and master if they are going to continue to be successful in the post-Affordable Care Act world.
One of the keys to success for commercial payers in the era of guaranteed issue is effective reporting. Medicare Advantage (MA) and Affordable Care Act (ACA) health information exchange commercial plans offer payers several mechanisms designed to compensate them for unexpectedly high-risk profiles or claim costs if they can effectively gather and report on their risk profiles as reflected in clinical and claims data.
On average, up to 15% of payer “earned” Centers for Medicare and Medicaid Services (CMS) reimbursements are lost each year because payers are unable to accurately capture and report on all of the data required.
For instance, consider that as much as 30% of all medical records contain unsubstantiated diagnoses. Only through fully capturing all conditions in a thorough end-to-end review, can payers realize accurate revenue over a claims-only view of a patient’s health profile.
To take full advantage of these programs and put more risk-based reimbursement dollars in the bank, payers need to master a new level of gathering and reporting on not just claims data, but clinical data as well, in an integrated, comprehensive and accurate fashion.
Internal server error