Health Risk Assessments: Why Not Just Any Provider Will Do

May 20, 2019 Jeanette Stern


Health Risk Assessments are an important tool in a health plan's Medicare Risk Adjustment arsenal.  There are a few different strategies for how to deploy Health Risk Assessments, or HRAs. There are also multiple strategies for picking which members to target for an HRA.  However, these strategies are not as important as choosing a good HRA provider.


Member Experience

Chronically ill members who have low contact with the healthcare system are the most cost-effective HRA visits.  These members aren't having medical encounters that record diagnosis codes, so even though they are sick, those illnesses aren't taken into account when calculating risk score and premium.  If a member has no diagnosis codes, their risk score and premium will be low, no matter what their actual health status is. This could leave insurers paying for costly admissions without appropriate reimbursement.  By assessing these members with an HRA, plans can ensure proper reimbursement based on a member's actual conditions.

The important thing for Risk Adjustment and Quality professionals to understand is that for some members, the HRA is likely their only encounter with a healthcare professional all year.  This is a crucial interaction that could lead a member to increased trust in health professionals and in the health plan. It could also do the opposite. A negative HRA experience could lead a member to have negative opinions about healthcare providers.  It may even make them less likely to seek care in the future. It will also be harder to perform a HRA with that member next year, when the plan needs to re-submit diagnosis codes. So, unprofessional and unpleasant HRAs will become less effective risk adjustment tools over time.   

Plans need to make sure that any HRA provider they contract with provides excellent service to members, from first contact to complete assessment.  Any negative member interaction risks member dissatisfaction with the plan. Since the plan recommends the HRA provider to their members, members associate the two, and sometimes think they're one company.   That, combined with the fact that the HRA may be the only healthcare evaluation a member receives in a year, should push plans to choose their HRA provider carefully. Not all companies can provide the high quality service members need.  


Meeting Goals

HRA providers that over sell their ability to assess members have the potential to derail a risk adjustment strategy.  Plans usually build expected premium into their budgets. Premiums for Medicare replacement plans depend on a projected risk score, and risk score projection usually takes HRAs into account.  Therefore if HRA goals aren't met, the plan risks missing financial goals.

It's hard for a plan to judge when an HRA provider is over promising their ability to complete assessments.  Many HRA providers may agree to a goal in good faith, only to find out later that they don't have the staffing levels required to meet it.  Neither party has any way of knowing that the HRA goal won't be met. That doesn't change the fact that the plan won't receive the correct premium for members who miss out on an HRA.  

The best way for a plan to determine whether or not an HRA provider can meet goal is by past performance.  An HRA provider the plan has worked with successfully in the past is likely to meet goal again in the future.  Plans can also try to gauge the history a provider has in their market. If a provider has never done a project in a plan's market before, they may not have the staffing needed to meet an ambitious goal.  


MedXM has a history of providing quality patient experiences.  It's also one of the few providers of both in-home and in-clinic HRAs, which allows for greater flexibility for members.  It also means that MedXM has access to more clinicians than other companies, which means it has more resources to make good on a promised HRA goal.  For more information on Health Risk Assessments, contact us.


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