A Regional Blue Plan: Optimized End-to-End Risk Adjustment Process

CHALLENGE – Multiple Vendors for Risk Adjustment, Retrieval and Coding

A regional Medicare Advantage Blue plan had sourced risk adjustment analytics, retrieval and coding services from multiple vendors. The client faced challenges in managing these services, and had a substantial vendor management overhead. The multi-vendor environment resulted in multiple hand-offs and touchpoints across vendors throughout retrieval and coding processes, leading to significant time spent in coordination. Additionally, the retrieval and coding vendors were unable to meet the agreed performance levels on yield, quality and timeliness.

SOLUTION: Simplified Risk Adjustment Process

The client engaged Ciox Health to provide an end-to-end risk adjustment solution for retrieval and coding. In order to simplify the client’s risk adjustment experience, Ciox Health adopted a consultative approach to understand the challenges faced by the client in the risk adjustment process. Leveraging industry-leading practices and its deep expertise in risk adjustment services, Ciox developed an end-to-end solution addressing the challenges faced by the client.

Ciox End-to-End Risk Adjustment Solution

Ciox End-to-End Ciox Health developed a full-service analytics solution, which leveraged client inputs, its proprietary algorithms, and knowledge of the provider data retrieval patterns and behaviors. This enabled the client to identify the optimal chart chases. With Ciox’s provider footprint and provider knowledge, it was able to exceed the initial yield targets. Furthermore, the seamless operations within chart retrieval and coding teams enabled Ciox to manage re-chases identified by the coding team, and chart fixes internally, without impacting client processes.

RESULTS: Higher ROI, Reduced Provider Abrasion

Utilizing Ciox Health’s end-to end-solution, the client realized higher program return on investment. Additionally, Ciox’s retrieval methods helped the client reduce provider abrasion. The seamless coding and retrieval operations and dedicated account management provided the client with a simplified risk adjustment experience with minimal hand-offs and friction.

At a Glance

Challenge

  • Significant overhead and difficulties in managing multiple vendors
  • Quality issues due to multiple hand-offs and touchpoints

Solution

  • Simplified end-to-end risk adjustment process
  • Analytics solution to target the optimal chases
  • Knowledge of provider data retrieval preferences to enhance retrieval yield
  • Seamless chart retrieval and coding operations
  • Dedicated account manager

Results

  • Higher program return on investment
  • Lower risk adjustment spend
  • Simplified risk adjustment experience
  • Lower provider abrasion

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