Gartner Research

5 Actions U.S. Healthcare Payer CIOs Must Take When Purchasing Risk Adjustment Management Systems

Published: 31 January 2019

ID: G00369402

Analyst(s): Mandi Bishop, Bryan Cole

Summary

Profitability in government health programs depends on complete and accurate coding of members’ health status. U.S. healthcare payer CIOs must prioritize analytics and verify AI capabilities when seeking new or replacing risk adjustment optimization vendors.

Table Of Contents
  • Key Challenges

Introduction

  • Government Health Program Profits Depend on Smart RAO Vendor Selection
    • RAO Is Not an Easy Market for Payer CIOs to Navigate
    • CIOs Must Expand Knowledge of RAO Vendors and Market Dynamics

Analysis

  • Seek Vendors With Differentiated Analytics Capabilities
  • Make Vendors Use Your Data to Demonstrate Their Capabilities
  • Probe the Strengths and Weaknesses of Vendors’ AI Tools
  • Evaluate Buying RAO and Quality Improvement From One Vendor
  • Invest in CDI

Gartner Recommended Reading

©2020 Gartner, Inc. and/or its affiliates. All rights reserved. Gartner is a registered trademark of Gartner, Inc. and its affiliates. This publication may not be reproduced or distributed in any form without Gartner’s prior written permission. It consists of the opinions of Gartner’s research organization, which should not be construed as statements of fact. While the information contained in this publication has been obtained from sources believed to be reliable, Gartner disclaims all warranties as to the accuracy, completeness or adequacy of such information. Although Gartner research may address legal and financial issues, Gartner does not provide legal or investment advice and its research should not be construed or used as such. Your access and use of this publication are governed by Gartner’s Usage Policy. Gartner prides itself on its reputation for independence and objectivity. Its research is produced independently by its research organization without input or influence from any third party. For further information, see Guiding Principles on Independence and Objectivity.

Already have a Gartner Account?

Become a client

Learn how to access this content as a Gartner client.