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Why risk adjustment teams should be upgrading to API technology

Thanks to API technology, building HCC risk profiles or risk adjustment profiles (RAPs) no longer has to be labor intensive and can lead to more meaningful insight into risk and the expected cost of care. Designed for use by developers and data managers at payors and health plans computing HCC risk adjustment profiles, CareEvolution’s Insight API ingests a FHIR bundle and calculates a risk score. With its Insight API and the other Orchestrate APIs, CareEvolution presents a more efficient approach to building HCC risk profiles with more complete data.

Intro to HCC risk adjustment

Hierarchical Condition Categories (HCC) risk adjustment is a method of adjusting capitation payments to health plans, either higher or lower, to account for the differences in expected health costs of individuals. Cleaner source patient data results in more accurate risk adjustment calculations, which can enable population health stratification and opportunities for improved clinical documentation.

The importance of accurate risk adjustment profiling

Measuring risk helps ensure the appropriate level of care is delivered to patients. A RAP is a measure of patient health that maps patient diagnoses (ICD-10 codes) with their demographics against Hierarchical Condition Categories (HCCs). The RAP is meant to reflect the severity of a patient’s diagnoses and the expected level of care required to manage their health. Medicare aligns its payments with the patient’s RAP, meaning payments will scale to match the complexity of care delivered. This is done to discourage healthcare providers from cherry picking patients (only taking on healthy patients) and to align reimbursement with cost of care.

Challenges with risk adjustment profiling

Data management teams supporting risk adjustment and quality at health systems and payers face challenges compiling a comprehensive patient health history from large volumes of patient data from multiple sources in disparate formats. This process requires semantic rationalization or “standardization” of terminology to handle uncoded data, poorly coded data, and free text. Even after format conversion and standardization, duplicate information may still span many pages, leaving data poorly suited to generating insights.

The data management teams tasked with creating risk adjustment profiles (RAPs), while they may be well versed in sourcing and reading ICD-10 codes, are rarely performing the sort of standardization, cleaning and consolidation required to remove redundancies and perform risk adjustment calculations. For large organizations with tens or hundreds of millions of patient records this can be a daunting process!

Revolutionize your HCC risk profiling with APIs

The Orchestrate APIs offer a better way to ingest data for HCC risk profiling. The Orchestrate platform is a set of cloud native APIs that extract actionable insights from large raw datasets such as FHIR bundles in a few simple steps, with no software to install or manage, and no set up or preconfiguration.

The Convert and Standardize APIs take the heavy lifting out of data cleaning and consolidation so that risk adjustment teams, patient care plans, hospital operations teams, payors and life insurance underwriting teams can have a single consolidated record of health history for faster and easier medical record reviews and risk assessments.

The Convert and Standardize APIs minimize data loss and by coding uncoded data, result in an enriched, more complete patient record. The enriched patient data can then be used to calculate the HCC risk profile, for more meaningful risk insight.

Getting started

The Insight API’s Risk Profile operation can be used to calculate Risk Profiles or RAPs for any number of patient records quickly and easily. Data managers and developers can try all of the Orchestrate APIs in our sandbox for free.