Insourcing: So you are thinking about internalizing risk adjustment . . .

We talk to health plans everyday that want to internalize risk adjustment.  Bottom line: It is a good idea.

Taking control and building an expert, internal risk adjustment team is one of the best tactics a health plan can take.  Here, we share an initial checklist of those areas needed for “in-sourcing”:

 Claims based HCC filtering
 RAPS filtering and submission
 EDPS compilation and submission
 Medical record suspect generation
 Medical record retrieval
 Medical record coding
 Chart warehouse
 Hospital outreach for electronic encounter compilation
 Member evaluation suspect generation
 Evaluation development
 Member evaluation provider network
 Member evaluation findings integration
 Tracking & closing gaps in care with member outreach
 Member care report cards
 Primary care physician medical home
 Metrics, benchmarks, ROI, reports, and performance monitoring

Much of this you can internalize cost effectively, but you still need to be diligent. We’ve helped several health plans analyze their programs and vendors to determine what to pull in-house.  Strategy, discipline, compliance and an engaged multi-disciplinary team willing to make decisions and push forward are critical elements for success.