Error message

  • Warning: "continue" targeting switch is equivalent to "break". Did you mean to use "continue 2"? in include_once() (line 1374 of /home/scioha2/public_html/includes/
  • Deprecated function: The each() function is deprecated. This message will be suppressed on further calls in _menu_load_objects() (line 579 of /home/scioha2/public_html/includes/

January 04 2018 | 0 Comments | 206 reads Average Rating: 3

The Risk Adjustment All-Stars: Five Key Players

by EXL Healthcare in Risk Adjustment

Risk adjustment enables the Centers for Medicare and Medicaid Services (CMS) to pay health plans based on the anticipated cost of covering care for the beneficiaries they enroll. Therefore, it’s important for health plans (and provider groups with percent of premium contracts) to get risk adjustment right. Perplexingly, though, risk adjustment is often handled by just a single department – or, worse yet, sometimes tacked on to somebody’s “day job.”

Taking such an approach is limited as single departments often have a narrow vision of organizational activities; silos often develop making it difficult to comprehensively address risk adjustment; and senior leadership typically is not involved in these independent efforts.

Risk adjustment should be a team effort. The following five departments can be key players:

#1: Quality. Typically quality departments are only involved in risk adjustment after the fact – and, therefore, have a limited effect on member behavior. If the quality department is involved in risk adjustment earlier though it can have a greater impact. For example, the quality department might proactively establish a specific goal such as increasing breast cancer screening by 10%. Having an established goal at the beginning of the year is much more effective than simply looking at the performance numbers at the end of the year.

#2: Member or patient engagement. These professionals work directly with members and patients and, therefore, have the ability to influence behavior. For example, if you have a diabetes program, staff who are reaching out to members to ensure compliance can also focus in on encouraging members to see their physicians in an effort to close care gaps related to breast cancer screening, chronic obstructive pulmonary disorder (COPD) or other health issues. While these care gaps are closed, documentation gaps for risk adjustment can be simultaneously addressed by the physician.

#3: Finance. Having the finance department, which typically acts as the investment gatekeeper, involved early on in the risk adjustment process makes it possible to secure the support needed to invest in risk adjustment initiatives. The finance department can also provide insight into the potential impact of payment changes.

#4: Contract/provider relations. When it comes to reimbursement, providers often fear that they're being underpaid while payers guard against mistakenly overpaying the providers they work with. The provider relations department can create the transparency needed to assuage such concerns. In addition, the provider relations department can provide a “line of sight” into payment changes.

#5: Technology. In today’s world, everything is electronic and a single disruption can have a negative effect downstream. The technology department can ensure that electronic systems are running smoothly and that data is managed optimally. In addition, the technology department can ensure that data is handed off among departments in a manner that ensures the integrity of the data as it traverses across the continuum.

By bringing all of these departments into risk adjustment efforts, healthcare organizations can create a winning risk adjustment program. For a more in-depth discussion of why this team approach is necessary and other risk adjustment best practices, tune into our webinar entitled “The Risk Adjustment Rallying Cry.”

Rate this Article:

Average: 3 (2 votes)

EXL Healthcare

Log in to post comments



Arun Rangamani
VP, Payment Services Delivery Leader

Ben Steverman
Chief Technology Officer

David Hom
Chief Evangelist

Jodi Siegel, MSHI, BSN, RN (Guest Author)
Director, wellness and care management

John Pagliuca
Vice President, Life Sciences

Lalithya Yerramilli
VP, Healthcare Solutions

Lesli Adams, MPA (Guest Author)
Director of Population Health Strategy, Oracle Corporation

Linda Pantovic (Guest Author)
Director of Compliance & Risk Adjustment, Scripps Health Plan Services

Mark Feeney
Life Sciences Consultant

Monique Pierce
Vice President, Business Optimization

Nayfe Faillace
Chief Compliance & Privacy Officer

Nicole Stec (Guest Author)
Senior Well-Being Manager, Banner Health

Priyanka Rajkumar
VP - SCIOXpert and Solutions, Analytics

Rena Bielinski
SVP, Strategic Accounts

Rodger Smith
SVP, Payment Integrity

Rose Higgins
SVP & GM, Data and Analytics

Subha Vaidyanathan
VP, Technology and Data Management

Taryn Bevilacqua
Compliance Director


Sign up to receive the latest SCIO news & insights, industry updates, event updates and more, right in your inbox.