Risk Adjustment

Master Your Risk Adjustment Process

You know the enormous impact risk adjustment has on your Medicare Advantage organization’s bottom line. But with all the encounter data involved—from diagnosis and condition codes to treatment and pharmaceutical codes—you may have no idea how to create order out of the chaos. Too many MAOs make data processing and management more complicated than it needs to be.

If you are still relying on staff to collect and process data, or if you’re trying to make old software tools work in a changing healthcare environment, you need to rethink your risk adjustment process. You can’t realize the reimbursements you are due if you keep doing things the way you have always done them.

You need a well-designed solution that addresses your current needs and can scale to meet future changes in your patient populations and government regulations.

Invest in new technology

Today’s risk adjustment software is designed with the user experience in mind. It’s much more like consumer software that is designed to be used by almost anyone with a computer or smart phone. Applications are more intuitive, with simple interfaces that are user friendly and don’t require hours (or even weeks) of training.

While you can invest in programs that handle individual activities, you’ll get the best return on your investment if you develop or purchase an integrated system that addresses every aspect of the risk adjustment process.

Just as you purchase affiliated software programs for all your office procedures—word processing, spreadsheets and presentations—that let you share content between them at the click of a button, your risk adjustment system should allow you to share your data across a multitude of activities and applications. It should be easy to do all the following tasks (and more) using integrated programs:

  • Collect and manage data from specific populations
  • Identify members with the highest HCC recapture opportunities
  • Select which members to action from a specific subset of a population
  • Launch campaigns to close HCC gaps to automate medical chart retrieval, coding and attestation letter production and mailing
  • Process Encounter Data to identify the financial impact of coding errors
  • Submit data to CMS in the proper format meeting the necessary requirements

Your system should automatically recommend and schedule workflows so you can more easily meet submission deadlines with encounter data that meets all the requirements of the Center for Medicare and Medicaid Services.

Turn to subject matter experts for direction

As smart as technology has become, it still can’t replace the wisdom and counseling of subject matter experts. When evaluating vendors for a new risk adjustment system, you should look for one that provides more than a package of individual solutions.

Ideally you should invest in a vendor who can assess your organization, your existing processes and your challenges and recommend best practices to meet your needs. They should be able to outline the interventions you can take for certain populations and provide a roadmap for rolling out your new technology—either one step at a time or all at once, depending on the kind of disruption it may potentially cause.


We simplify the management of member programs by making it radically more efficient, and increasing value to healthcare organizations and their members

Don’t Miss Our Presentation on Surfacing Non-Compliant Codes at RISE West