Risk Adjustment Strategy Allows Large Medicaid Plan to Increase Risk Score

Doctor and patient looking at digital tablet


Medicaid plan
Western region


Improve risk score


Change Healthcare’s Risk ViewTM solution


Risk adjustment projects realized an estimated 7:1 ROI, after factoring in cost of FTEs and the Risk View license.

The Customer:

A large Medicaid health plan in the Western United States with more than 500,000 members.

The Challenge: Improve Risk Scores

The plan started working with Change Healthcare in March of 2010 in an effort to increase its risk score by applying advanced analytics. The plan sought to coordinate the work of 12 provider relations staff members, who were charged with contacting providers and members as part of the plan’s risk adjustment strategy.

The Solution: Develop Outreach Strategies Targeting Members with Large Risk Score Gaps

The plan dedicated a project manager to work with the Change Healthcare team on developing several prospective outreach strategies. The plan’s field staff enlisted the cooperation of providers to contact members who had not received care, despite the existence of a medical necessity. The team also contacted members with large risk score gaps. TANF Adult, TANF Child, and SSI members were included in the outreach projects. To calculate revenue impact, the plan considered the chronic nature of conditions which had not yet been reported, as well as the per member per month (PMPM) rate for the population.

The Results: Significant Revenue Boost, Better Management of Data

The plan used Change Healthcare’s Risk View™ solution to target members and providers and manage the data for its outreach initiative. By using resources more effectively and driving proactive outreach, the plan realized a significant revenue boost. After accounting for the cost of FTEs and the Risk View license, the plan recognized an estimated overall ROI of 7:1.

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