Important Steps in Better Risk Adjustment in Healthcare. US healthcare


1. Member-Provider Connections

Establishing meaningful connections between members and healthcare providers is crucial for successful risk adjustment. Primary care physicians (PCPs) play a central role in ensuring better care and monitoring for members, documenting health statuses, and fostering active engagement between members and providers. Programs that encourage regular check-ups, wellness visits, and screenings, along with incentives like gift cards, promote adherence to recommended procedures. Additionally, call-to-action programs and in-home assessments contribute to comprehensive care.


2. Accurate Medical Charting and Coding

Accurate charting and coding of members' health status are vital for effective risk adjustment. Health plans can achieve this through ongoing provider education, prospective charting to capture chronic conditions, and leveraging new technologies such as artificial intelligence for value-based care. Concurrent coding expedites the billing cycle, while retrospective coding serves as a last resort to validate potentially missed health conditions. Regular monitoring of coding quality and accuracy is essential for success.


3. Provider-Directed Programs

Incentivizing healthcare providers to proactively reach out to their assigned members is an effective strategy. Programs offering bonuses for completing annual wellness visits, comprehensive documentation, and tracking chronic condition reconfirmation rates contribute to successful risk adjustment. Provider encouragement programs play a crucial role in ensuring providers actively engage with health plan members, leading to more accurate medical records and claims data.


4. Data Reconciliation and Monitoring

Given the multi-faceted nature of the encounter submissions process, health plans must track the flow of data across different domains. Macro-reconciliation helps uncover reasons for fallouts between domains and various internal and external systems. Micro-reconciliation focuses on reconciling different data domains, correcting discrepancies, and continually ensuring data quality and integrity. CMS and HHS provide valuable resources and tools to aid health plans in the reconciliation and monitoring of encounter data.


5. Stakeholder Coordination

Encounter submissions involve three functional domains: charting, claim processing, and encounter processing. Successful coordination between IT, finance, data processing, and claim processing teams is crucial for ensuring encounter quality and completeness. Health plans may choose to use external partners to navigate this complex process efficiently. Coordination efforts aim to create multidisciplinary teams that are laser-focused on encounter quality and completeness, leading to successful submissions and accurate risk adjustment outcomes.

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