This article was originally posted on RISE’s website on January 10, 2023 here.

As marketplace enrollment continues to climb and concurrent risk adjustment gains traction, health plans must find innovative ways to improve financial and clinical outcomes. Adopting automated coding and analytics processes at scale will enable Affordable Care Act (ACA) and Medicaid plans alike to better understand the health of their populations, engage members more effectively, and keep pace with a rapidly changing health care environment

ACA enrollment has skyrocketed to record levels yet again in 2022. While this is a huge win for the Biden Administration’s efforts to expand access to affordable care, managing the needs of such a large, diverse population is no easy task. Given the unique challenges ACA plans face, embracing strategies such as automation and advanced analytics will be much more effective than attempting to retrofit Medicaid Part C risk adjustment strategies. As the Centers for Medicare & Medicaid Services (CMS) pivot toward a concurrent risk model, implementing a technology-driven approach can also benefit Medicaid plans as well, allowing them to perform targeted member interventions, expand access and equity, and improve financial and clinical outcomes.

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