Prospective Risk Adjustment
Even though outsourced prospective services for Medicare Advantage (MA) programs are a relatively new product in the risk adjust industry, its impressive yield results have garnered the attention of most MA health plans. Prospective is providing an important strategy to compensate for the revenue shortfall created by current and future reduction of payments by CMS, particularly since a prospective service can have significantly more financial impact than raising revenue premiums or cost cutbacks as a result of decreasing benefits.
As one of the early pioneers in developing prospective services, Leprechaun developed numerous approaches to a prospective service to determine which model provided the most optimal yield results. After two years of development, it was determined the most successful and popular implementation requested by health plan customers was a turnkey full service model.
In 2008, Leprechaun customers experienced an average improvement in compensation of Per Member Per Year (PMPY) of $3,721 - $6,152 and an average ROI range of 5.2 - 10.5. Early 2009 results indicate even better results.
As a revenue optimization product, Prospective provides health plans the benefit of identifying and documenting an accurate health status that can have a three to ten times higher financial impact than a retrospective review. In addition, health plans obtain financial compensation six to nineteen months earlier for the same date of service than a retrospective review.
| Leprechaun's Prospective is a turnkey full service utilizing our specially trained clinician network to perform in-home member evaluations. Our clinician training and custom evaluation forms are specifically tailored to optimize the member evaluation in the shortest and most cost efficient manner that meets CMS guidelines. As compared to health plans who utilize their own resources, using the Leprechaun turnkey service has resulted in more evaluations being completed in shorter amount of time with significantly better yield. In addition the Leprechaun Prospective provides recommendation and systematic directives that supplement the health plan's disease/cases management program. |  |
The Leprechaun Difference
- Consistently high yields across all customers
- > 95% clinical accuracy
- Specially trained clinicians for optimizing member evaluations to Medicare Advantage guidelines
- Member customized evaluation forms
- Efficient evaluation form design covering a broad number of disease cohorts including diabetes, pulmonary, neuropsychiatric, cardiovascular, gastrointestinal, bone/joint, renal/genitourinary, hematologic/oncologic
- Integration with a health plan's care management initiatives
For more information, please download our Product Brief which provides details of features and benefits and a description of our Prospective Services.
If you'd like our White Paper on Prospective Case Studies, then please contact our Business Development professionals.
