Do you have a comprehensive and effective risk adjustment program?


Monday, October 22, 2018 | By Mike Nemeth

Do you have a comprehensive and effective risk adjustment program?

Many health plans focus on sweep dates and code capture while working in some prospective outreach for members, but are you optimizing your Risk Adjustment (RA) activities and tools to improve coding documentation and data submissions throughout the entire year? If not, you should be!

RA is a year-round commitment. Programs and tactical activities need to prospectively be engaging members/providers all year long using focused analytics. Whether it’s analyzing documentation gaps, evaluating member historical care patterns, evaluating provider performance, or active prospective and retrospective campaigns, there is always something you can be working on to maximize your opportunity to submit high quality, valid encounter data.

Below we’ll focus on some tactics that help support a comprehensive and effective year-round RA program. First, to drive continuous departmental constancy and promote organizational RA awareness, it’s useful to compartmentalize work into fiscal quarters. I recommend RA programs use the following Quarter by Quarter Keys to Success.

1st  Quarter Keys to Success

  • Establish understanding of the population and membership mix. Build baseline risk data on new enrollees, understand historical behavioral patterns of retained members and assess the overall impact of membership loss on revenue and risk scores.
  • Incorporate additional data sets to develop robust member profiles that drive engagement approach.
  • Evaluate member and provider data quality – address any discrepancies in data to improve the success of your tactical programs for member and provider engagement. Accurate and valid data will improve engagement rates and expedite program implementation.
  • Coordinate within the organization by sharing the plan of action, create alignment between initiatives where applicable and develop consistent messaging to members and providers.
  • Identify tactical programs to be leverage, timing of program implementation and what members will be included in which campaigns.
  • Develop coordinated plan for provider engagement and incentive or payment programs.
  • Launch tactical programs for provider and member engagement.
  • Finalize any prior year chart review and submission activities for Final Sweep.
  • Initiate chart review and submission activities for Mid-Year Sweep.
  • Develop supplemental submissions for ACA deadline.
  • Assess prior year plan outcomes to validate effectiveness of programs and make any strategic or tactical plans.

2nd Quarter Keys to Success

  • Address any challenges with strategic partners or barriers to program implementation and success.
  • Monitor provider performance and utilization of shared data to address open documentation, coding and care gaps.
  • Initiate provider incentive payments or reporting as applicable.
  • Suspecting and chart chase program kick off for MA population Initial sweep.
  • Finalize ACA submissions.

3rd Quarter Keys to Success

  • Evaluate program results – Outcomes against activity, are programs yielding desired results? Looking at engagement rates, encounter performed and documentation captured by provider, NP, or vendor performing the services allows you to validate the program success. Don’t assume a high contact rate equates to high outcomes, simply making contact with a member isn’t the end of the activity.
  • Evaluate chart findings for comparison to expectations all the way through submissions.
  • Reprioritize members based on risk level or shift targeted engagement strategy.
  • Maintain coordination with internal and externals stakeholders for program alignment with other key initiatives or changes to activities.
  • Continue engagement of providers and partners to drive program performance and outcomes.
  • CMS Initial sweep submissions for MA.
  • ACA Baseline submissions.

4th  Quarter Keys to Success

  • Final push for prospective campaigns.
  • Chart Review activities for ACA and MA.
  • Focus on high priority members with remaining gaps.
  • Communicate the push to providers early in the 4th quarter to gain buy in on availability to see members.
  • Ensure partners are aligned to the 4th quarter push and have capacity to address any program adjustments or shift in tactical activities.

In addition to the Quarterly Keys to Success, I also recommend that plans implement basic RA maintainability activities every month to ensure nothing is missed. 

Monthly RA Program Maintance Activities

  • Member analytics and stratification to address any changes to targeted members
  • Establish baseline risk profile for new enrollees
  • Evaluate program results
  • Course correct tactical approach as needed to maximize program effectiveness
  • Provider reporting and data sharing
  • Monitor data submissions to Federal and State entities to ensure all of the diagnosis codes capture in prospective and retrospective programs is being recognized.

By following these simple Quarterly Keys to Success you can begin to build a year-round program that leverages ever-changing member and provider data and provides mechanisms for actionable retro and proactive activities. 

Health plans are finding that RA programs have become a critical business process and that a comprehensive, effective risk adjustment strategy is equally critical. Whether you operate a Medicare Advantage or Health Insurance Marketplace plan, DST Health Solutions Revenue & Quality Management Solutions are a single source for enterprise management of risk adjustment and quality of care. Let us show you how we can help you make the most of the resources you have available for the best possible outcomes.



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