Prior to the COVID-19 pandemic, risk capture was almost an afterthought for ACA populations. Today, it’s an integral part of any risk adjustment program. The 2023 benefit year alone is resulting in $10.3B in transfer payments. Today, we want to discuss what’s driving it and how the right risk adjustment partner can help ensure the accurate, compliant capture of risk adjustable conditions for ACA members.
Post-pandemic, ACA populations have swelled with open enrollment hitting 21.4 million. The average age has declined, and policy updates combined with tight submission windows have made ACA risk adjustment a priority while simultaneously navigating tighter submission windows than other populations.
Today we want to cover challenges and offer solutions that can change the way payers and providers engage with ACA risk.
Affordable Care Act Population Changes
The post-pandemic policy changes around state and federal Medicaid ramped up population churn, moving between 8-24 million people out of the population. For these people, there was one real option: coverage through the Affordable Care Act.
This population size and demographic shift towards a younger average age puts additional pressure on effective, accurate risk capture. With healthier members of a younger population, ACA’s payment transfer structure moves funding towards sicker populations within the risk pool regionally. With nearly a quarter (23%) of ACA participants carrying more than one HCC, the accurate picture of their risk-adjustable conditions needs to be captured to ensure appropriate funding is available to provide care.
With the core of ACA risk adjustment payment transfers drawing on funds allocated for healthier patients to care for those with more chronic conditions, the priority of earlier, more accurate capture of conditions is absolutely necessary. (This is compounded by the addition of maternal and infant codes.) In doing so, better care management over subsequent years is supported as chronic illness progresses and the full picture of population health is accurately captured, ensuring transfer payments are the result of need, not deficiencies in risk capture.
Navigating Risk Through ACA Policy Updates
Alongside population and demographic changes, permanent transfer payment changes started in benefit year 2023. This has already resulted in ACA state transfers climbing to 14.2% of total reimbursement. As a result, the stakes have grown. As CMS noted, the 2023 benefit year resulted in $10.3 billion in transfer payments. More granularly though, the right risk adjustment strategy and solution suite can mean the difference in risk accuracy for individual plans ranged from nearly $1.8 billion dollars in transfer payments to a $300 million reimbursement increase.
Finally, there’s the additional complication of timing. It’s not breaking news that ACA submissions don’t have the flexibility of Medicare Advantage. Neither surfacing missing HCCs to improve accuracy of disease burden, nor deleting incorrect codes to drive compliance post-deadline is allowed under ACA submission rules. Nor is there the luxury of time: for ACA, payers have only four months, compared to upwards of 18 months for Medicare Advantage.
With a four month window to ensure the full picture of your population’s ACA risk is captured, the right technology partner isn’t just a good option, it’s the only option.
Challenges Require Solutions
Accurate, compliant risk adjustment with any population requires a thoughtful approach to both the individual population and the right application of technology. In the simplest possible terms, this means first acquiring the data, whether electronic or via manual chart retrieval. It means pulling that data into a centralized location and standardizing it.
Only then, can the right application of AI and machine learning be put to work, leveraging all of that data to prioritize charts via suspecting, surface missed codes, and identify codes that lack sufficient evidence to ensure compliant, accurate risk capture. It also all needs to be delivered through a platform that supports managers and coders, with the right customization and lack of end-user abrasion.
Apixio has spent well over a decade bringing together market leading, AI-powered technology with focused expertise. This has resulted in a scalable risk adjustment solution suite that solves the complexities of ACA risk adjustment for clients of any population size.
It’s time to turn ACA risk adjustment from a pain point to another success story within your risk adjustment strategy. Fill out the form below, we’d love to see how we can help.