Healthcare

Affordable Care Act (ACA)

Achieve optimal ACA program performance by leveraging our solutions, which enable accurate assessment of market risk, utilization projections, and premium evaluation.

About

Affordable Care Act (ACA) implemented risk adjustment and reinsurance programs, providing financial support to health plans that enroll higher-risk individuals, thereby mitigating potential financial losses and enhancing revenue stability.

Advantages

Boost financial performance

  • Uncover improvement opportunities with in-depth assessment.

  • Enhance revenue and cut costs with targeted strategies.

  • Bolster financial outcomes with data-driven decision-making.

Enhance risk scoring

  • Ensure payments reflect the true level of risk in your market.

  • Improve financial stability by matching data and population.

  • Accelerate revenue by adapting to patient health risks.

Assess IVA RADV process and performance

  • Reduce penalties and risks with validated EDGE submissions.

  • Reinforce regulatory reporting with improved data accuracy.

  • Optimize IVA and RADV performance to drive higher revenues.

Solution: Predictive Models

RaLytics has developed predictive models to determine the risk of specific disease conditions. The models are based on care patterns indicated in the utilization data associated with specific conditions.

RaLytics models give issuers the opportunity with their own utilization data to do the following:

1

Use RaLytics models to predict HCCs reported in EDGE but unlikely to be supported in the IVA RADV audit. Identifying areas of IVA vulnerability allows the plan to prioritize medical record acquisition efforts

2

Use RaLytics models to predict HCCs likely to be currently under treatment to secure complete EDGE and supplemental file submissions.

  • Prioritize provider feedback and CDI efforts.

3

Use RaLytics models to assist plans in estimating their risk relative to the risk in the market as part of their analyses for estimating their transfer payment.

  • Models combining Edge and client data can help plans estimate overall risk in the market.
  • Leverage client data to estimate individual plan risk.