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Risk Adjustment 2021
Which Vendors Deliver Best?

author - Ryan Pretnik
Ryan Pretnik
author - Jennifer Hickenlooper
Jennifer Hickenlooper
November 2, 2021 | Read Time: 8  minutes

Payer organizations, provider-sponsored health plans (PSHPs), and provider organizations are expressing growing interest in adopting risk adjustment solutions that provide a wide variety of capabilities and enable consolidation to fewer vendors. Many vendors say they can provide a comprehensive solution, but which actually deliver? Based on the feedback of 163 respondents, this report examines vendor performance across key customer experience metrics and validates customer adoption across the broad spectrum of risk adjustment capabilities.

A Note about Vendor Participation

KLAS invites all relevant vendors to participate in our research by sharing current customer lists, which KLAS keeps confidential. For this report, two key vendors in the market either provided a partial client list (Change Healthcare) or declined to participate (Optum). Interviewed customers of these vendors were identified mostly through KLAS' own efforts or through KLAS' existing relationships with customer organizations. Please see the table on page 8 for more details on vendor transparency.

Vendor Snapshots & Customer-Validated Usage

Risk adjustment offerings differ widely in breadth, with some providing focused functionality and others offering more comprehensive capabilities. The graphic below provides a brief snapshot of each vendor as well as customer-validated usage across the pillars of the risk adjustment framework.

vendor snapshots and customer validated usage

Inovalon and Optum Are Compelling for Their Comprehensive Offerings but Fall Short in Meeting Expectations

likely to recommend vs keeps all promisesThough they are market share leaders and often considered, Inovalon and Optum struggle to meet customer expectations, often due to outdated technology or unkept promises. Inovalon is seen as having broad capabilities and expertise for both quality management and risk adjustment. However, satisfaction among current customers is low overall, and almost 80% of respondents report the vendor does not keep their promises. Customers say the product was oversold and that Inovalon is poor at following through on promised functionality and issue resolution. Additionally, some customers have felt nickel-and-dimed. The limited number of interviewed Optum customers report achieving desired outcomes—such as high chart-collection rates—but several describe the software as clunky and hard to use. Relationship challenges are also reported; more-frustrated customers describe Optum as inflexible and say they have to escalate issues to get them resolved. Overall, 44% of Optum respondents do not plan to keep their solution long term. The limited number of interviewed users of Change Healthcare’s comprehensive offering report a better overall experience, with 80% saying the vendor keeps promises. Some inconsistencies prevent higher satisfaction. More-satisfied users say the solution is reasonably priced and provides the analytics and coding they need to create visibility and drive change within their organizations. Less-satisfied users describe the technology as expensive, clunky, and outdated. Cotiviti (limited data)—who has a large number of quality analytics customers—is seen as offering a mature risk adjustment solution and is used by some of the largest health plans in the country. The chart-retrieval capabilities are a strength; customers describe other areas as dated and needing improvement. Customers would like Cotiviti to be more proactive in keeping promises and resolving issues. Ciox Health’s large base of chart retrieval customers reports that the vendor delivers the expected number of charts; a few would like Ciox Health to be more proactive in pursuing hard-to-retrieve charts.

EXL’s Strong Analytics Offering Expanding to Broader Capabilities; Advantasure’s Technology Lacking

A few vendors that don’t yet provide comprehensive offerings have still expanded beyond chart retrieval and are starting to gain market energy. EXL has recently begun expanding their analytics-focused offering to include broader capabilities, with early adopters of these capabilities reporting good satisfaction. Those using EXL particularly for analytics highlight the ease of use and report outcomes such as better data visibility, improved scores, and shared savings. Both groups see EXL as a partner and are optimistic they will achieve additional outcomes as the vendor continues to build out their offering. Episource is described as easy to work with and has partnered with customers to continue expanding their broad risk offering. Customers particularly highlight the chart retrieval and coding services; customers feel that other areas—such as health assessments—were oversold and need more development. While Episource is seen as committed to new development, this process is sometimes a little slower than customers would like. Advantasure offers both services and software. The technology is viewed as less developed than other solutions (customers still send information via fax) and as needing better reporting functionality. Customers have not achieved all of their desired outcomes, and a couple note that they stay solely because of incentive programs that are available only through an Advantasure partnership. Vatica Health provides both managed services and technology, and customers see them as having a unique risk adjustment offering. Customers find the platform easy to use, and some feel the vendor has exceeded their expectations: one reported outcome is better partnership between payers, providers, and members. Additionally, customers feel the data helps providers more proactively close care gaps. A few customers mention that the vendor may be having trouble scaling their service offering as they take on more customers.

key product metrics

Apixio’s AI Capabilities and Client Success Program Drive Accuracy, Efficiency; Health Fidelity’s Difficult Implementations Causing Struggles

quality of implementation vs ability to drive outcomesVendors offering AI (natural language processing [NLP] and machine learning [ML]) are often used to improve HCC coding accuracy and close care gaps. Implementing these capabilities can be difficult, and poor implementations can prevent organizations from achieving expected outcomes. Apixio’s customers highlight the vendor’s NLP and ML for coding. Apixio’s support and partnership—which start at implementation and continue beyond—have helped customers achieve a positive ROI, and customers note that the client success managers help them continue to achieve new outcomes. Talix’s solution is embedded in the EMR and uses NLP to help with chart review and coder training. While customers report positive outcomes, they say the initial implementation was more difficult than expected and the training lacked structure. Most customers rave about Talix’s support; a few have experienced issues caused by staff turnover or by the company trying to scale to match growth. Health Fidelity is seen as having a very customizable system with strong NLP. Customers report improved risk scores and greater visibility into provider engagement. Achieving these outcomes isn’t always easy—some customers say difficult implementations, lack of training, and unexpected integration hurdles prevent the product from working as expected and cause usability and workflow issues.

Pulse8 & Optum Customers Most Likely to Consider Leaving

Feedback on the long-term plans of Pulse8, Optum, and Advantmed customers comes from limited samples. Despite Pulse8’s solid analytics technology, almost half of interviewed customers are considering leaving; some cite deteriorating relationships and support since Pulse8 partnered with Veradigm (an Allscripts business unit). For the reasons already examined above, Optum also has a large number of customers considering their options. Less satisfied customers of Advantmed—who is known especially for their chart retrieval and coding capabilities—do not view the vendor as part of their long-term plans, citing staff turnover, cost concerns, slow issue resolution, and reporting challenges.

part of long term plans

Pareto’s Analytics and Proactive Partnership Lead to High Satisfaction; Overall MedInsight Experience Improving

proactive service vs overall satisfactionPareto Intelligence’s web-based analytics tools and dashboard are often used for chart review and educational analytics for providers. Consulting services and regular meetings can be included with the software, and many customers say these options solidified Pareto as part of their team and have driven significant value. The risk models and customization of MedInsight’s analytics platform are seen as differentiating strengths. A move to the cloud and a recently updated user interface have led to functionality improvements and contributed to a significant increase in overall satisfaction. However, the customizations often lead to system breaks during upgrades and create issues with both data accuracy and the ability to get data into the system. Customers wish MedInsight were more proactive in identifying and solving these issues, but they are mostly happy with the vendor and the support they receive from CSMs. customers report bumps getting the system up and running, but once it is implemented, they are able to achieve expected outcomes, especially around improving their population health management and reducing care gaps. Many describe the vendor as proactive and engaged; a few note that when problems arise, Arcadia is a bit too reactive and slow to resolve the issues.

Risk Adjustment Pillar Definitions

The graphic below outlines the many pillars that fall under risk adjustment. See first chart in the report for vendor-specific details regarding validated customer adoption under each pillar.

risk adjustment pillar definitions

About This Report

Each year, KLAS interviews thousands of healthcare professionals about the IT solutions and services their organizations use. For this report, interviews were conducted over the last 12 months using KLAS’ standard quantitative evaluation for healthcare software, which is composed of 16 numeric ratings questions and 4 yes/no questions, all weighted equally. Combined, the ratings for these questions make up the overall performance score, which is measured on a 100-point scale. The questions are organized into six customer experience pillars—culture, loyalty, operations, product, relationship, and value.

customer experience pillars software

In addition to the questions in the standard evaluation, KLAS also asked respondents to answer two supplemental questions specific to the risk adjustment market. The first question gathered scoping information regarding which framework capabilities organizations are currently using from their risk adjustment vendor. The second asked respondents whether they have plans to expand this usage. The data-collection window for these supplemental questions was shorter, resulting in some cases in smaller sample sizes than for the standard evaluation.

Sample Sizes

Unless otherwise noted, sample sizes displayed throughout this report (e.g., n=16) represent the total number of unique customer organizations interviewed for a given vendor or solution. However, it should be noted that to allow for the representation of differing perspectives within any one customer organization, samples may include surveys from different individuals at the same organization. Ratings from these individuals are aggregated in order to prevent any one organization’s feedback from disproportionately impacting a solution’s score. The table below shows the total number of unique organizations interviewed for each vendor or solution as well as the total number of individual respondents.

Some respondents choose not to answer particular questions, meaning the sample size for any given vendor or solution can change from question to question. When the number of unique organization responses for a particular question is less than 10, the score for that question is marked with an asterisk (*) or otherwise designated as “limited data.” If the sample size is less than 5, no score is shown. Note that when a vendor has a low number of reporting sites, the possibility exists for KLAS scores to change significantly as new surveys are collected.

about this report
author - Elizabeth Pew
Elizabeth Pew
author - Natalie Jamison
Natalie Jamison
author - Natalie Jamison
Project Manager
Natalie Jamison
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This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2024 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.