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Rationalize your plan’s approach to risk adjustment

Accurate submissions allow the health plan to maximize revenue, but plans often don't have the right technology in place.

5 min read


Rationalize your plan’s approach to risk adjustment

Babel Health

Health plans that operate in government markets know all too well the challenges of risk adjustment. To combat these challenges, most have cobbled together point solutions that can leave them vulnerable to errors, compliance problems and lost revenue. SmartBrief spoke with Babel Health CEO Robert Dunn about the problems plans face under these systems and Babel’s vision for a better way.

Risk adjustment has been a persistent challenge for health plans. Why is this such a tough area?

Babel Health CEO Robert Dunn

The landscape has changed rapidly over the last several years. The slow transition from RAPS to EDPS, the introduction of the EDGE server for ACA, and the eclectic state-to-state landscape for Medicaid encounters have left plans with a potpourri of kluged solutions. This has created a complicated management problem, required additional staffing and training, and made RA submissions dependent upon and subordinate to all of the other health plan information technology priorities. Babel Health provides full operational control and process transparency through a single data management tool and multi-program user interface rationalizing and standardizing all submissions for all government programs.

What are the cost and compliance implications of risk adjustment for plans that do it well, and for those that don’t?

There are specific compliance and regulatory requirements that must be met, and penalties and sanctions associated with untimely or inaccurate submissions. In addition, the use of multiple vendors increases day-to-day operating costs and chance of errors. Accurate submissions allow the health plan to maximize revenue.  A partnership with Babel Health enables plans to rationalize and improve the entire process with one data acquisition tool; pre-validation editing based on CMS, state, and health plan requirements; and a single user interface that allows effective utilization of health plan human and technology resources.

What are the problems associated with drawing data from disparate sources, and how can they be overcome?

Multiple vendors or internal processes that gather information from the same data sources and culminate in a single submission create logistical problems, multiple versions of the same raw data, different validation routines and increased operational costs. This approach means poor process transparency, abdication of control and a lack of insight into the total picture. In addition, there is no ability to analyze financial and submission data across programs where necessary. Babel’s R3 Insight tool allows financial analysis, submission gap analysis and the ability to perform pre-submission financial analysis, what-if scenarios, reconciliation of RAPS/EDPS and pre- and post-submission analytics for all Medicare, Dual, Medicaid, and ACA encounter submission programs.

What are some common or particularly problematic errors that appear in encounter data?

Problem areas include missing and inaccurate data from health plan claims and provider databases, lack of editing and poor monitoring of provider data acquired through chart retrieval, EHRs, and third-party vendors handling. These issues may involve durable medical equipment, pharmacy, eligibility and other data. Babel’s pre-validation process exposes these issues and provides the visibility required to correct data through Babel’s user friendly cross-walk process, error-correction workflow, batch editing and systems integration tools that allow data to be properly updated in the health plan’s source of truth.

Many health plans piece together technologies to cover a range of needs in an area like risk adjustment. What challenges has this created, and what benefits might plans see with an end-to-end approach?

 “Patchwork” solutions for submissions create increased points of failure and increased costs for collection and management of data. These scenarios require excessive data storage and processing power, systems integration development, staff support and redundant training. They also carry the administrative and financial burdens of as many as 10 vendor contracts and their associated fees.

The result for plans is they are less able to maximize revenue, and they risk missing important CMS deadlines.

Babel’s single solution delivers capabilities including an error-correction workflow, data cleansing and repair, and an easy to use cross-program user interface allows plans to create a closed environment that is more easily managed.

Babel consolidates and normalizes patchwork systems with a real-time platform that runs on a CMS-approved secure AWS environment, with unlimited dynamic expansion, no capital costs, easy implementation and world-class customer support for compliance and technology. One vendor with the only fully integrated Risk Adjustment solution in the marketplace.

Robert Dunn is a healthcare technology, operations, and consulting executive with 35 years’ experience. Over the last ten years, Robert has served as CEO and COO for top vendors in the payer space and an executive consultant to software, BPO, and systems integration firms. In addition, he has provided management consulting to health plans; his work has focused on technology and strategic planning decisions integrating and rationalizing commercial, government, and exchange systems into the most efficient operational model, as well as finding the best leverage of financial investments.