3M Risk Optimization Services can help plans receive their full potential reimbursement under the payment transfer reconciliation as part of the Affordable Care Act (ACA).
Through a member-level grouping process that simulates the risk adjustment methodology mandated by Health and Human Services (HHS), 3M analytics and reports enable exchange-eligible plans to understand and capture the true risk of their member population.
Under the Affordable Care Act (ACA), the payment transfer process calls for funds to be transferred from plans with lower-risk enrollees to plans with higher-risk enrollees to protect against adverse selection. This process applies to non-grandfathered individual and small group plans inside and outside the health insurance exchanges.
As a result, plans must ensure that the risk of their exchange-eligible population is accurately captured under the hierarchical condition categories (HCC) model, HHS’s required risk-adjustment methodology, so they can minimize the possibility of leaving money on the table at the year-end payment transfer reconciliation.
This process can be problematic because providers may not be coding diagnoses as accurately as possible, and certain cases may not trigger a condition under the HCC model. For example, patients with chronic conditions who do not visit their doctors would not have sufficient experience to trigger an HCC assignment. Thus, it falls to the plans to make sure their members’ risk is accurately reflected under the HCC model.
3M Risk Optimization Services give plans the analytics to perform ongoing identification and management of both network and member opportunities. This allows them to be accurately and completely reimbursed at the time of the payment transfer reconciliation.
Through the 3M member-level grouping process, which simulates the HCC model, the analytics and reports show:
Member-level reports inform provider and patient outreach efforts; identify members who have had gaps in coding; and pinpoint patients who appear to have an underlying illness burden not captured by the HCCs.
Network-level reports identify coding variation and deficiencies from a network perspective; highlight network performance trends over time and comparisons across the network; and examine coding variations at the individual physician, practice or ACO levels.
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