For payers offering Medicare Advantage products, Part C and Part D, the risk-adjustment cycle represents a significant challenge to achieve both transparency in operational processes and forward visibility of financial results. Audits and potential enforcement actions increase risk and make it imperative for payers to have accurate documentation and solid financial reporting, data reconciliation and adjudication processes for reporting to CMS and other organizational stakeholders.
With a lens to the future, some payers are taking a new approach and combining operational risk adjustment data with actuarial modeling to improve their efforts to deliver quality care to members, eliminate unnecessary costs and improve financial results. These payers see opportunities for enhancing their existing programs and contracting activities with specific, actionable data. These efforts are focusing on:
- Increasing confidence in financial forecasts by clearly communicating the revenue cycle to stakeholders
- Identifying the programs or activities that are meeting the needs of your members and the organization
- Improving care coordination by determining if your members are receiving attention to their known medical conditions and proactively identify members being potentially under-treated
- Benchmarking performance by measuring whether the level of medical conditions being treated for your enrolled members is on par with other health plans in your local and regional market
- Optimizing provider networks with protocols that incent providers and health systems to deliver the highest quality care and value to members
An approach that creates a balanced view of financial and operational results can improve financial transparency and support the on-going evolution of your organization’s Medicare Advantage products. For key considerations for combining your financial and operational analytics, read more here.
About the Author:
Michael L. Rasmussen, FSA
Director, Actuarial Services
Mike is a Director of Actuarial Services in Optum’s Atlanta office with over 20 years of actuarial experience. As a senior actuary and project manager, he provides strategic and technical assistance with pricing, risk adjustment, reserving, and financial projections. Mike specializes in providing actuarial consulting services to Medicare Advantage plans.