Risk Adjustment: A Compliant, Efficient and Medicine-Based Approach

Master risk adjustment with a compliant, efficient, and medicine-based approach. Learn how to optimize RAF scores, navigate changing CMS expectations, and integrate data for accurate reporting. Secure your organization's success in healthcare's evolving landscape.

As premiums continue to decrease – Health Plans, IPAs, MSOs, and medical groups must implement plans to ensure a precise RAF score. To obtain these, healthcare organizations must not only recapture the enrollee’s prevalent conditions but compliantly report clinical conditions as they appear. 

Several organizations have been “playing with numbers” to project future premium increases or decreases to support their strategic planning. Any risk adjustment program must have several critical elements to bolster its foundation and a strategic plan to increase efficiency. These elements include coding and billing policies, workflow mapping, quality assurance process reviews, and a solid compliance program that delivers high-standard results. 

As the government (CMS) expectations on risk adjustment change and are more difficult to understand and manage, ACOs, Medicare Advantage Plans, IPAs, MSOs, and medical groups should adopt a mixed flexible model with the IT capacity to evolve with retrospective, concurrent, and prospective initiatives. Data integration with care management, case management, and disease management is critical. Processes and initiatives must be streamlined to provide compliant and flawless healthcare outcomes. 

Data accuracy is a vital component of our program: DATA VALIDATION is a must. Data for an IPA or ACO comes from multiple external sources, but this data and data reporting IN and OUT is essential to organizational performance. Achieving quality improvement and risk score accuracy has never been more critical to healthcare competitiveness and viability, and that is why capturing, processing, and submitting risk adjustment data to CMS must be accurate, timely, and complete. 

Providing continuous education to our providers, coders, and clinical documentation improvement specialists should be part of the organization’s culture. We must give them access to knowledge to facilitate their learning (onsite or virtually) to improve coding practices, create a better understanding of risk adjustment, provide continuous access to updates, and produce better validation rates.

Quality committees, compliance committees, defined best practices, and adoption of guidelines are also essential elements that will impact clinical and financial outcomes. Now is a pivotal moment when quality and risk adjustment determines whether an organization – from health plans to individual providers – will thrive or die.

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