Today’s reformed healthcare environment of increased regulations and quality-based payments, combined with declining CMS payments/reimbursements, has made revenue optimization a critical success factor for health plans.
Traditional compensation methodologies can no longer be assumed, but rather require a strategic focus to increase Star Ratings to ensure a bonus payment and maximize reimbursement for HCC risk adjustment factors. The goal is not to maximize revenue, but rather to optimize it by taking into consideration both the benefit and cost of achieving these desired outcomes.
From relevant bits of information a health plan must form a picture of a member’s condition. But how accurate are these pictures? As more information is collected, we learn that this member isn’t just diabetic. He also has COPD, CHF, hypertension and hyperlipidemia. The expected reimbursement from CMS really should be much higher, because that member has a greater illness burden than the plan initially thought.
By adapting to new data sources and technologies, health plans have an opportunity to improve their Star ratings and ultimately affect both their top and bottom lines. A successful improvement strategy requires strategic data analysis on both macro (overall Star rating) and micro levels (each of the 48 variables).
When applied to healthcare, successfully segmenting the population into specific groups provides a solid understanding of what motivates a person, what holds them back, how they prefer to communicate, and the frequency of communication. It also identifies people who are generally adverse to engaging.
The Role of Data Federation in Revenue Optimization
“Just as states federate to form a country, data residing within independent data stores can form what appears to be a virtual database to the end user, without ever copying or transferring the data. The relational databases that are the foundation of healthcare can continue to be used and now be can leveraged by bringing in unstructured data sets, such as consumer data or wellness data by county, to improve the customer experience as well as financial and operational performance.”