Clinical Data Acquisition and Review for a Volatile ACA Risk Pool

The ACA marketplace has entered its most volatile period since launch. With enhanced premium tax credits expired, effectuated enrollment down from 22.1M to 19.2M and projected to settle near 17.5M by year-end, and bronze-plan share jumping from 30% to 40% in a single year, every traditional assumption underlying an ACA risk adjustment program is being tested at once.

In this session, we’ll explore a precision-driven model for chart review designed for high churn and data volatility. ACA issuers will learn how to identify eligible members and encounters, convert external data into confirmed diagnoses before enrollment lapses, and capture secondary and comorbid conditions across the full record. Attendees will leave with actionable strategies to ensure precise risk capture, prevent revenue leakage, and make every chart review count in today’s zero-sum market.

Key Takeaways:

• Understand how to locate the member before you chase the chart, ensuring retrieval resources are both targeted and efficient
• Learn how to beat the 90-day grace period clock by prioritizing and chasing the right chart at the right moment
• Explore best practices for onboarding the sicker “new-to-plan” population, focusing on suspecting that converts to coding as ACA enrollment shifts
• Gain practical guidance on using concurrent coding alongside retrospective review to maximize risk capture in low-density pools, as well as see where NLP-driven pre-coding triage fits for prioritizing chart review and ensuring completeness