Payers stratify premiums for a given benefits package by the member's relationship to the policy holder, and if permitted, by age or gender. This stratification discourages enrolling higher-risk, ...

Artificial intelligence (AI)-enabled tools such as natural language processing (NLP) have been integrated into a wide range of applications, including risk adjustment coding tools, for greater ...

Faced with new government regulations, Medicare Advantage (MA) organizations should be utilizing technology to increase the accuracy of their coding, mitigate their risk, and ensure appropriate care ...

Claims data, which form the foundation of risk adjustment in payment for health care services, may reflect efforts to capture more—or more severe—clinical conditions rather than true changes in health ...

Risk adjustment could continue to draw on diagnoses from medical claims, but in a more targeted fashion that focuses on diagnoses that supply additional predictive information and are less affected by ...