Description: Risk adjustment in government regulated health plans has been around for over two decades. Yet the strategies for promoting risk score accuracy haven't varied much during that time. Most health plans, physician groups, and vendors promote chart reviews and/or in-home assessments as the primary vehicle for collecting data not perceived to be present in the routine claims submission and adjudication stream. We know that most organizations trying to coalesce encounter data from multiple sources often fail to ensure that all relevant data is ultimately submitted to CMS or a state Medicaid agency. Crucial data, often with significant financial value, frequently gets lost in the data pipeline, somewhere between the provider's billing system and the health plan and/or its vendors. Because 837-formatted data is difficult to read, it complicates payers and vendor’s abilities to track encounter data so that every service delivered to patients is credited to the applicable risk adjustment formula. It is incumbent upon successful risk-adjusted entities to be able to track encounter data, identify processes and/or vendors which may be mangling or losing data, in order to ensure that risk scores are sufficiently accurate to be compliant with plan sponsor requirements and to ensure appropriate revenue to the health plan or provider group.

Description: Last year, the COVID pandemic significantly increased the pace of change in the life insurance industry, particularly in Accelerated Underwriting (AU). In the past, underwriting process changes occurred relatively infrequently and over a matter of years. Now, with new data sources and predictive models constantly evolving, the frequency of underwriting enhancements and decisioning changes, particularly in AU programs, is occurring every few months. With so much change occurring quickly, how can a company effectively monitor and understand the effects of these changes to make continuous adjustments with confidence and agility? Well-designed data visualizations allow a reviewer to navigate and comprehend detailed results quickly because our brains can process data in a picture format more than 15 times faster than text. Today’s advanced BI tools can make AU program monitoring more efficient and help companies adjust quickly to the results from program changes.