Don’t Take Risks with Risk Adjustment Programs: Key Capabilities to Improve Performance

By April Gill

Many in the healthcare industry are acutely aware that Medicare Advantage organizations continue to face challenges in the changing risk adjustment environment.

This includes reimbursement pressures, increased scrutiny from CMS and a significant and ongoing shift to consumer-directed care. While this pressure is increasing, new approaches to managing risk adjustment in an integrated and holistic way are also emerging.

That’s History

Historically, risk adjustment operations have been financially focused. Many organizations have outsourced the requisite, because diverse capabilities are required. This is to ensure the appropriate coding and documentation of disease burden within populations and to identify opportunities that improve quality of care. This single-source approach provides limited visibility around performance which leads to sub-optimal results. It also promotes misaligned incentives creating increased RADV risk and creates many points of contact with members, which can negatively impact member experience.

Moving Forward

To create a best-in-class risk adjustment organization, health plans are shifting towards consumer and provider-centric solutions. Three foundational aspects are required to make this shift:

  • Utilize an “open innovation” concept by reconciling internal and external capabilities,
  • Integrate care management and quality initiatives, and
  • Place even more emphasis on the member experience.

Open Innovation leverages the acquired understanding of external capabilities that exist in the marketplace in conjunction with internal resources to create solutions that when combined, create enhanced business value. This allows plans to match resources to functions based on core assets and expertise rather than convenience. It also leverages internal capabilities and core strengths. 

These solutions support a more personalized member experience. It better aligns incentives between members, plans, providers and vendors to maximize performance and return on investment. It also provides the opportunity to leverage greater visibility to oversee performance and offers the flexibility to make strategic changes when needed to maximize value and outcomes.

A Solutions Partner

Welltok Analytic Services (formerly Predilytics) provides advanced analytics that leverage machine learning with a combination of customer data and a large proprietary consumer database of 270 million Americans. It supports an important component of risk adjustment operations. We understand the unique relationship health plans/MAOs build with their members and provider networks. We share a similar vision to improve the health and wellness of the communities we serve and to improve access to high-quality, affordable care. Through our work, we also understand the opportunities and challenges inherent in managing population health within the framework of risk adjustment operations and can offer impartial support and value.