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Exchange plans are missing out on millions of dollars


A new Express Scripts report highlights risk reporting gaps and offers advice for plans looking to close those gaps to ensure accurate risk payments

Exchange plans may be missing out on millions of dollars because of undocumented risk, according to a report by Express Scripts.

The report, Unmanaged Risk, Untapped Opportunity, in partnership with HealthScape Advisors, highlights the common areas where risk reporting gaps occur among public exchange plans, and offers advice for plans looking to close those gaps to ensure accurate risk payments. 

According to the report, the four common risk reporting gaps are due to:    

· Lack of timely member insights. New market entrants and membership movement across payers prevent health plans from building long-term risk profiles of members. This forces plans to use non-targeted outreach calls or end-of-year chart reviews, which are suboptimal means of closing documentation gaps and managing cost of care.

· Inconsistent member behavior. Many documentation gaps are a byproduct of inconsistent member engagement or behavior. Establishing a minimum of one appointment per year for members with illnesses in the hierarchical condition categories is necessary for risk adjustment, which yields long-term savings, improved care focus and reduces emergency room visits and other high-cost care.

· Incomplete medical claims. Often, due to unavoidable circumstances, doctors simply don’t code everything plans need to know about your members. When someone visits a doctor for a sinus infection, but doesn’t mention their chronic COPD, it makes it impossible for the physician to code properly for an accurate risk adjustment score. In addition, physicians are focused on patient care, not patient coding. Providers, or their administrative staff, may inadvertently choose the wrong code. This results in patients getting the right care, but plans getting the wrong financial result.

· Reporting delays. The gap in time from medical care to claim is a healthcare reality. However, a lack of early indication of an undiagnosed patient condition means plans can’t effectively implement patient interventions. This can result in inefficient management efforts, higher overall plan costs and decreased patient care.


“Health plans are not receiving credit for an estimated 10% to 20% of their population’s true risk, leaving millions of dollars on the table simply due to inaccurate risk capture and reporting,” says Julie Huppert, vice president, government programs at Express Scripts.

In the most recent year, HealthScape also found that 1 in 4 plans reversed their fortune, meaning they went from receiving a risk adjustment payment to paying out or vice versa, further indicating not only a fluid marketplace and significant shifts in the risk of populations being managed by health plans, but also inconsistency with capturing risk and reporting it.

While accurate reporting is a critical component of success in the marketplace, it’s only one part of successfully managing risk,” Huppert says. “Fostering a healthier member population is equally important. Health plans that achieve a healthier, more adherent member population that mitigates downstream health issues are best equipped to succeed in overall profitability.”

According to Huppert, health plans should consider additional ways to manage patient health to avoid spending and mitigate risk, for example:

·         Improving medication adherence by leveraging predictive modeling tools.

·         Leverage specialist pharmacists to improve coordination of care

·         Reduce prescription fraud, waste and abuse.

·         Leverage smart formulary designs to reduce prescription costs.

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