Risk Adjustment: Compliant Efficient & Medicine Based Approach


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

By: Carlos Arias, MD, MPH, CPC, Apr 25, 2017

As premiums continue to be reduced, Health Plans, IPAs, MSOs, and medical groups must have plans in place that ensure an accurate 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 support its foundation, and a strategic plan to increase efficiency. Some of these elements will be coding and billing policies, workflow mapping, quality assurance process reviews, and a strong compliance program that delivers a high standard of 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 model that is flexible, mixed, and has the IT capacity to evolve with a retrospective, concurrent, and prospective initiatives.  A must-do is data integration with care management, case management, and disease management. We must streamline our processes and initiatives to provide health care outcomes that are both compliant and flawless.


The accuracy of data is a key 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 are 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 create better validation rates.


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