2.5.24
At the end of each calendar year, 数十亿美元在参与以州为基础的健康保险市场的健康计划之间转移, which offer Affordable Care Act (ACA)–compliant plans. These dollars, often referred to as risk adjustment transfer payments (RATPs), topped $18 billion nationwide in 2022, equivalent to 10% of the total premiums for ACA plans.1
ACA风险调整计划旨在通过(通过ratp)将资金从健康参保人的计划重新分配给病情较重的参保人，从而降低参保人的风险. It was implemented, in part, 鼓励各计划参与健康保险市场，并努力为所有计划创造一个财务公平的环境. 然而，该计划和ratp已成为ACA计划经济的战略因素.
RATP是一个零和游戏，因此每年也会有赢家和输家. 随着风险调整费用逐年上升，无论是绝对金额还是保费的百分比，一个健康计划在ACA风险调整项目中的表现越来越与它的整体成功联系在一起. Poor performance can be crippling, 两项值得注意的ACA计划面临着近2美元的挑战.7 billion in RATPs in 2022.2 这种RATP水平极难解释，并将导致RATP出现赤字. 这样的赤字将对ACA计划产生实质性的负面影响.
The challenges faced by plans in 2022, as well the macro RATP trends, 应该为所有参与ACA风险调整计划的健康计划敲响警钟吗. 至关重要的是，健康计划必须优化其风险调整流程，以确保取得成功成果并在市场上获得竞争优势.
以下是计划可以用来在ACA风险调整程序中脱颖而出的几个策略.
Keys to Success
1. Invest in advanced analytics and reporting.
- Robust Data Integration Systems: A holistic patient view can only be achieved with integrated data. 确保您的系统可以聚合来自不同来源的数据，例如电子健康记录(EHRs), health information exchanges (HIEs), and pharmacy records—to get a complete picture of patient health.
- Data Validation: Regularly scour your data for anomalies. Consistent validation can identify and rectify errors, ensuring risk scores genuinely reflect patient health. 主动的数据验证和协调方法可以提供准确性和安心.
- Continuous Monitoring and Reporting: Regularly monitor your risk adjustment processes and outcomes. 这不仅确保了合规性，而且有助于确定需要改进的领域.
- Error Resolution Protocols: 是否有明确的策略来处理出现的差异.
2. Engage your members and providers.
- Easy-to-Use Member Portals: 积极参与的会员可能会提供更好的数据，并积极主动地关注自己的健康. That starts with having an easy and interactive consumer tool. 用户友好的平台可以鼓励会员在跟踪和管理自己的健康方面发挥积极作用.
- Timely and Relevant Communication: 定期运行状况检查的自动提醒可以增加数据点并确保最新的运行状况信息.
- Regular Training for Providers: An informed provider can be a key ally. 让供应商了解和更新文档要求. 因为临床数据的完整性和准确性对风险调整至关重要, training can significantly reduce discrepancies and errors.
- Documentation Standards: 定期的供应商研讨会或研讨会可以澄清文档要求, leading to more accurate data submission.
- Feedback Mechanisms: 允许供应商对风险调整过程提供反馈，确保持续改进.
3. Ensure Compliance
Maintaining regulatory integrity is nonnegotiable. 保持最新的ACA和相关的指导方针可以防止潜在的挫折，并使您的组织能够利用任何新的机会.
- Regular Audits: 定期检查将确保流程符合监管要求，并降低处罚风险.
- Training: 让您的团队了解最新的遵从性需求，以确保一致的遵守. 同样重要的是，任何过程或程序变更都要在整个组织中及时沟通和实现.
- Vendor Oversight: 健壮的供应商监督机制确保第三方约定不会损害风险调整过程. 供应商监督应该有强有力的治理，包括清晰和客观的合同条款, performance metrics and standards, and regular communication with each vendor.
- Well-Defined Roles and Responsibilities: 明确角色和职责是风险调整过程成功的基础. By creating well-defined roles and responsibilities, 组织可以确保有效地处理风险调整过程的每个方面. It reduces ambiguities, enhances collaboration, 并确保流程中的每一步都由最有能力的人来执行.
4. Understand your existing and projected membership.
In the simplest terms, 风险调整计划的成功是获得(或保持)预期成员目标的功能, 了解您的ACA人群的护理要求或风险, 并有效地管理您的ACA人群的医疗云顶集团. 要做到这一点，重要的是对成员的需求进行回顾性和前瞻性的评估.
- Retrospective Reviews: 深入到过去的记录，以确保没有条件被忽视，捕捉任何遗漏的收入.
- Prospective Strategies: By predicting future health events, you can better allocate resources and plan for care interventions.
Winning the Zero-Sum Game
在ACA风险调整计划中取得成功是一种微妙的平衡行为，需要对细节进行细致入微的关注, forward-thinking, consistent oversight, and endless coordination. 通过关注这些改进领域并保持积极主动的方法, 支付方可以确保他们的操作既高效又合规.
Learn More About our Payer Services
Edited by: Matt Maslin
2. http://www.cms.gov/files/document/unpaid-by2022-ra-charges-memo-10-26pdf-508-compliant.pdf
