Doctor contemplating risk

The Metamorphosis of the Risk Adjustment Market

The risk adjustment space is transforming before our eyes. In the beginning, vendors were heavily focused on service, but technology is catching up. The customer base is changing too. Payers used to dominate. But as more and more providers switch to value-based contracts, risk adjustment software may soon become all the rage among both payers and providers.

What Customers Have

When we ask providers and payers what risk adjustment software they use, we tend to get the same answers. The overwhelming response is, “We pick a safe vendor.” A safe vendor usually implies one of four options: Optum, Change Healthcare, Inovalon, or Cotiviti. These companies are well known, have been around for a while, and have the most market share. We call them the Big Four.

What Customers Are Looking For

The question is whether the Big Four can offer all the functionality and service that customers need. Healthcare organizations are looking for excellent analytics that will help them understand the risks of their populations. Customers want natural language processing and machine learning. They want a partnership. They want a vendor that will keep their promises. And most of all, customers want outcomes.

We wanted to know whether there were any other options for excellent risk adjustment software, so we did some digging. The result is our Risk Adjustment & Analytics 2020 report. Here we break down the complex landscape of the risk adjustment world:

risk adjustment and analytics framework

The truth is that there are vendors other than the Big Four that can offer solutions that drive outcomes. Companies like Apixio, SCIO Health Analytics, and Ciox Health are keeping their promises to vendors and driving tangible outcomes. There are some fantastic options for customers who are looking for supplementary software.

drives tangible outcomes vs keeps all promises

Customers praise SCIO Health Analytics and Apixio for their excellent support. Health Fidelity’s technology is beyond the curve with its natural language processing and strong risk analytics engine. Fans are cheering on Ciox Health and MedInsight as they develop their technology and seek to serve their customers well. And as Advantasure starts to dig in a little more to deliver new technology and partner with their customers, we may see the vendor blossom.

What Customers Will Buy

There is a strong future for risk adjustment and analytics with a gradual migration to value-based care. That is good news for the healthcare industry, including payers, providers, vendors, and patients. The more aware that providers and payers become of the potential risks and illnesses of their populations, the more effective and faster their interventions will be. Quality risk adjustment vendors could potentially save the healthcare industry billions of dollars.

As KLAS keeps its eyes on the market, we may see the Big Four partnering with other risk adjustment and analytics vendors or making adjustments to their customer service to keep up with a transforming market. We may also see these up-and-coming vendors catch up with the longtimers and disrupt the industry. We will probably see some new players. We are the watchmen; we will tell our readers what we see. Check out our current report for further observations and stay tuned for future insights.



     Photo Credit: Adobe Stock, fizkes