Revenue Management

We develop and implement strategies to help clients succeed in the post-reform environment.

Revenue Management Organizational Design and Implementation Support

Intervention Design, Workflow Development and Implementation

Encounter Data Lifecycle Assessment

Evaluation of Product and Provider Network Strategies

  • Supported the establishment of a Commercial Revenue Management function (which handles strategies and tactics related to risk adjustment performance), including the design of the organizational structure and the development of internal processes to support matrix function coordination

  • Performed local-based member economics and analytics to establish strategic direction and priorities related to marketing individual and small group products, including aspects of: targeting member cohorts, product offering and selection; distribution channel optimization; and retention and attraction strategies.  

  • Analyzed commercial claims data capture and reporting process, including the evaluation of provider coding intensity and persistency, to prepare strategies and tactics for commercial risk-adjustment programs through a cross-functional team that included all major functional areas of the plan

  • Performed end-to-end review of diagnostic data elements in client's data warehouse to identify potential loss of data through the adjudication process

Client Need

Client requested HealthScape’s assistance to prepare for the conversion of the under 100 insured market to a risk-adjusted, community-rated model.

HealthScape Approach

  • Facilitated risk-adjustment educational session with key stakeholders
  • Completed one-on-one interviews with key stakeholders to assess responsiveness to the implementation of risk-adjustment policy
  • Analyzed client’s risk-adjustment data capture against our experience in other markets to identify data capture weakness and opportunities for improvement
  • Reviewed data elements captured in client’s data warehouse to identify potential loss of data through adjudication process
  • Assessed current strategic initiatives of the plan to improve diagnostic risk capture
  • Developed pilot programs related to new provider and member engagement to improve diagnostic risk capture


  • Identified significant opportunities to improve persistency, timeliness, and intensity of diagnostic coding
  • Captured additional members for disease management programs not identified through current processes
  • Helped prepare client for conversion through customized strategies and tactics related to the specific characteristics and capabilities of the plan

A Risky State of Affairs

State by state results of risk adjustment results by parent company

Risky Business the Sequel - 2014 Risk Adjustment Results

Analysis of HHS estimated Risk Adjustment transfer payments and Reinsurance receivables

2016 Risk Adjustment Final Rule

Analysis of the 2016 risk adjustment model final rule changes and implications for health plans

2016 Proposed Risk Adjustment Model Changes

In this article, we review the 2016 proposed risk adjustment model changes, the impact on health plans, and key next steps to prepare

Final Rule – “Three Rs”: Additional Insights from the Front Lines

In this article, we provide insights into the Final Rule for Reinsurance, Risk Corridor and Risk Adjustment programs.

Three Rs - Welcome to the New Government Markets: Individual and Small Group

In this article, we discuss the critical impact Risk Corridors, Reinsurance, and Risk Adjustment will have on health plans.

Edge Server Business Implications

In this article, we discuss the financial, operational workload, and compliance implications associated with claim file submission to the Edge Server for Reinsurance and Risk Adjustment payment calculation.  

Service descriptions
Representative experience
Case study