Availity Blog

Three Tips to Optimize Risk Adjustment


8.22.2016 By SUSAN BELLILE, Principal, Health Plan Risk & Quality


Risk adjustment is used to calculate the underlying health status of a health plan’s population. For Medicare Advantage, it is the most significant factor in determining a health plan’s reimbursement. For exchange plans established under the Affordable Care Act (ACA), it determines whether the plan will receive additional funds or be asked to pay additional money at the end of the year.

Today, risk adjustment is also an important component of value-based care models in which health plans and providers are compensated for the quality of care they deliver, rather than individual services. In order for a health plan to be reimbursed appropriately or for a health plan to effectively share risk with providers, there is a need for comprehensive and accurate information about a member’s current health conditions.

Here are three ways health plans can optimize risk adjustment:

1. Embrace digital

 By digitizing the process of capturing information needed for accurate risk adjustment a health plan can reduce the amount of paperwork it has to manage for risk assessments. A digital solution also establishes a single destination for patient information, which can be accessed by multiple departments within the health plan.

2. Leverage a multi-payer portal for providers

 A multi-payer portal enables providers to have a single point of access where they can complete essential documentation that feeds the risk adjustment process for all the health plans with whom they do business. More convenience increases the likelihood providers will adopt and use a solution.

3. Consolidate documentation and make it digital

 Making it easy for providers to complete risk adjustment documentation increases the odds they will complete and submit patient information to the health plan. A “smart form” that contains pre-filled fields such as the provider’s name and address, questions specific to a patient’s diagnosis, and doesn’t have be faxed but can be sent digitally, makes it simpler for the provider and increases the timeliness with which it’s sent to the health plan.

The bottom line is risk adjustment is here to stay and health plans must optimize their risk adjustment processes to receive accurate reimbursement from the federal government. The extent to which health plans can achieve this on their own remains to be seen. It’s highly likely they’ll need expertise and assistance from external vendors.

You may also be interested in our eGuide Roadmap to Success: The Primary Challenges of Risk Adjustment for Health Plans.

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