UPMC Successfully Extends Risk Adjustment to Medicaid via Provider Risk Capture

With COVID-19 jobless claims exceeding 62 million Americans, Medicaid enrollment is expected to swell in the coming year. Both payers and providers must prepare now for the coming shift in their revenue mix as commercial membership declines. Risk adjustment, a process for fully representing the risk in a covered population, is often ignored or de-prioritized in Medicaid business lines given the zero sum nature of reimbursements. In this webinar, see how UPMC overcame the complexities of adjusting for Medicaid risk with a provider-focused capture strategy at the point-of-care and post-encounter, while improving compliance and performance measures.

Originally presented December 8, 2020

  • Learn how COVID-19 is affecting enrollment patterns and increasing the demand for Medicaid coverage
  • Understand how Natural Language Processing technology can be used to interpret unstructured clinical data like physician notes from the EMR and why that is critical to accurately identifying population risk
  • Discover how UPMC leveraged technology to help the care team drive documentation gap closure and deliver value without disrupting their existing patient-centered workflow
  • Uncover the lessons learned, outcomes attained, and roadmap utilized for implementing a successful Medicaid risk capture program alongside adjacent at-risk populations

Meet the Panelists

Adele Towers, MD MPH CRC FACP
Director, Risk Adjustment
UPMC Enterprises

Dr. Towers is the Director of Risk Adjustment for UPMC Enterprises, a practicing physician, and an associate professor of medicine. She is directly involved in the development of healthcare related technology, with emphasis on use of Natural Language Processing (NLP) for Risk Adjustment coding and use of Clinical Analytics to optimize clinical performance. Prior to this role, she has served as the Medical Director for Health Information Management at UPMC with responsibility for CDI and inpatient coding denials.

Dr. Towers has been on the faculty in the Division of Geriatric Medicine at the University of Pittsburgh for over 25 years, and continues to see patients at the Benedum Geriatric Center in UPMC. She is the former Medical Staff President at UPMC Presbyterian, and her prior positions have been as Vice Chair for Quality Improvement and Patient Safety for the Department of Medicine, Medical Director of the Benedum Geriatric Center and Medical Director of Primary Care at the Western Psychiatric Institute and Clinic. Dr. Towers has presented the experience at UPMC with use of NLP for coding at multiple regional and national conferences.

Davlyn Nauman
Director Analytics – Medicaid/CHIP Programs
UPMC Health Plan

Davlyn Nauman is Director of Analytics for UPMC for You and UPMC for Kids at UPMC Health Plan. In that capacity, she is responsible for overseeing the analytics that drive business decisions for the Medicaid and CHIP products. This includes clinical, quality, operational, and risk adjustment focuses.  Ms. Nauman has more than 12 years of experience with UPMC Health Plan, all with the UPMC for You team; growing from an analyst on the team to Director of the analytics department. Ms. Nauman’s education includes a B.S. in Mathematics from Slippery Rock University and M.A. in Statistics from the University of Pittsburgh.

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