Description: This session explores the far-reaching changes to how clinical data will be sourced, processed and consumed in many payer use cases including risk adjustment, quality measurement, care management, claims adjudication, prior authorizations, and other payer functions. Robust, interoperable data exchange is a prerequisite for value-based care. Clinical data will be increasingly accessible to augment administrative (claims) data via standardized Fast Health Interoperability Resources (FHIR, pronounced 'fire'), at a fraction of the cost of a accessing a traditional medical record and in real-time. On May 1, 2020, HHS issued a final rule implementing interoperability and the patient access provisions of the 21st Century Cures Act of 2016, although enforcement has been delayed into 2021 because of the COVID-19 pandemic. The new regulations promote, “HHS’s vision and strategy for achieving a health information ecosystem within which all individuals, their personal representatives, their health care providers, and their payers are able to send, receive, find, and use electronic health information in a manner that is appropriate, secure, timely, and reliable to support the health and wellness of individuals through informed, shared decision-making, as well as to support consumer choice of payers and providers.”Once enforcement begins, CMS and the Office of the National Coordinator for Health Information Technology (ONC), have the authority to mandate adoption of interoperability requirements, and also penalize payers and providers for non-compliance or the delay and withholding of data.This ‘digital transformation’ of the clinical data ecosystem has far-reaching implications for enabling technologies including Natural Language Processing (NLP) and entire segments of services and vendors. It will eliminate many departmental barriers, duplication and error sources for health plans and impact every department and the underlying economics of delivering and managing care.

Description: Medicare-Advantage Organizations (MAOs) are often under intense pressure to increase revenue. The ACA dramatically changed the incentives by which MAOs achieve financial success. With benchmark rates growing only as fast as FFS Medicare rates, many MAOs rely on risk scores and quality bonuses as their primary source of additional revenue.There are a not insignificant number of MAOs that are either under scrutiny by federal investigators, exposed to whistleblower lawsuits, and some even paying large penalties to resolve False Claims Act liability for providing inaccurate risk adjustment information (e.g., $270 million paid by Healthcare Partners/DaVita Medical Holdings in October 2018).Is it possible to operate a risk adjustment program that is both compliant with applicable federal regulations and sub-regulatory guidance yet still generate the revenue to ensure that Medicare-Advantage plans are financially viable in the marketplace? The presenters believe that not only is true compliance (as opposed to the mere appearance of a compliance program) a requirement for success, it is a necessary pre-condition for both MAO profitability and to ensure that risk scores are an accurate representation of member morbidity.