The business model for commercial healthcare payers is changing fundamentally in the wake of the Affordable Care Act (ACA). A major element of this change involves a shift in the way health insurers that serve the small-group and individual markets are paid, with the government taking premium dollars away from plans that serve lower-risk members and transferring it to plans that serve higher-risk members.
As payers manage the transition to this form of risk-adjusted payment, they are implementing new business processes, technology solutions, and partnerships that can help them retain premium dollars and avoid legal action under the False Claims Act. This white paper focuses on best practices that commercial payers are adopting as risk adjustment becomes a critical business process.
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