Gartner Research

U.S. Healthcare Payer CIOs Must Seize Risk Adjustment Opportunities

Published: 19 June 2017

ID: G00326517

Analyst(s): Bryan Cole

Summary

Many payers still see risk adjustment optimization as a secondary function related only to revenue enhancement. Yet, RAO has evolved and is now a business-critical competency for overall payer success. It's time for CIOs to implement RAO technology by working with stakeholders across business lines.

Table Of Contents

Analysis

  • Risk-Adjusted Revenue and Provider Reimbursements Drive Payer Financial Performance
    • Medicare Advantage
    • Managed Medicaid
    • Affordable Care Act (ACA) Individual and Small Group Segments
    • Non-ACA Commercial and Provider Markets
  • CIOs Must Drive RAO IT System Deployment
  • RAO Has Become More Complex and Technology-Driven, Pushing CIOs to Advance Vendor Selection and Implementation
  • Risk Adjustment Operations Share Underlying Workflow Steps, Allowing CIOs to Consolidate IT Systems Across Business Lines
  • Diminishing Returns to Current Optimization Efforts Slow Payer Revenue Gains, Motivating CIOs to Expand RAO Capabilities

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