Democratize Risk Adjustment Data Reporting
ACA - Risk Adjustment Submissions
Mission:
At Gita Health, we're on a mission to simplify CMS, HHS, State specific Risk Adjustment (RA) data reporting needs of Health Plans participating in various Government Programs such as Medicare, ACA and Medicaid.
Challenges:
Here are the key challenges we see in the Risk Adjustment (RA) space:
Subject Matter Experts (SMEs) are scattered across various healthcare organizations, leading to a fragmented knowledge base.
Existing solutions are often bloated or black boxes, making it challenging for Health Plans to effectively manage their Risk Adjustment Program data reporting results, which directly impacts their financial performance.
Gita Health Teams Commitment:
To tackle these challenges head-on, Gita Health is committed to:
1. Demystifying Risk Adjustment (RA) guidelines through clear and accessible articles and video resources.
2. Leveling the playing field for all Health Plans by building a robust community that engages and expands the pool of SMEs.
3. Developing a cutting-edge platform that showcases our advanced data processing capabilities, enabling transparent and efficient Risk Adjustment Submissions.
At Gita Health, we believe in empowering Health Plans with the knowledge, tools, and community support they need to navigate the complexities of Risk Adjustment (RA) Submissions successfully.
We would like to build products that support the needs of the Health Plans operating in the the various Risk Adjustment (RA) Programs in Phases. Below we can find information on the various phases and the Risk Adjustment (RA) program stats.
ACA - Phase 1 (Enrolled Members - 21M, Health Plans* - 7613)
Medicare Advantage - Phase 2(Enrolled Members - 31M, Health Plans* - 1035)
Medicaid - Phase 3 (Enrolled Members - 85M, Health Plans** - 843)
** # of Health Plans as of data published in 2024
**# of Health Plans as of 2021
Phase 1 - ACA
Primer
A primer on ACA Risk Adjustment program can be seen in the KFF Article published a couple of years ago and the below table summarizes Risk Adjustment program.
Data Submission Tool
At Gita Health, we're tackling one of the most complex and high-stakes challenges in healthcare - Risk Adjustment (RA) Submissions for the Affordable Care Act. As you know, this is a zero-sum game where health plans live or die based on accurate reporting of risk data to capture appropriate compensation.
Our Data Submission Tool will level the playing field and empower health plans to maximize their risk capture. Here's what we're building:
1. Intelligent Data Pipelines
Our focus is on building fully-managed data pipelines streamline the flow of massive enrollment, medical, and pharmacy datasets with identification rules, automated data validation, and reliable data exchange.
2. Automated Business Rules Engine
We will translate complex HHS business rules into an automated rules engine. This enables enforcement of guidelines at scale prior to submission, dramatically reducing rejection rates through intelligent processes.
3. Data Exchange - Transparency into XML Blackboxes
The dialogue between HHS and Health Plans takes place through XML data exchanges. We will build intelligent processes that dissect the submission and response dynamics to refine the understanding of submission accuracy and efficiency.
4. Prescriptive Analytics
Create reporting that empowers all of the stakeholders with predictive and prescriptive analytics. Automated strategies will be surfaced to help identify qualifying vs non qualifying risk adjustment member claims impacting the Plan Average Risk Score.
Our focus is to deliver a robust industry platform that will harmonize people, processes and technologies. We invite you to experience a new paradigm of collaborative data intelligence driving transparency, financial integrity and improved healthcare outcomes. Join us in this mission as we revolutionize risk adjustment through innovative, responsible solutions.