How to create a comprehensive risk adjustment program

Plans are under growing pressure to transform and innovate their risk adjustment strategies. Increased regulatory scrutiny on documentation practices as well as new opportunities unlocked by technology-driven innovation are creating new standards, and health plans need to adopt a more proactive and integrated approach to stay current.

The transition to CMS-HCC Model V28 and the oversight on Health Risk Assessments (HRAs) are just two examples of a larger trend to reduce ambiguity and increase the specificity and accuracy of risk data. The adoption of digital data and the application of AI technologies are both helping to overcome silos and integrate workflows, enabling risk adjustment to track risk in real time and move closer to the point of care. This reduces administrative burden and improves both the speed and quality of data—but also requires careful planning.

Responding to the need for streamlined operations and reduced abrasion, health plans should focus on improving their risk adjustment strategies, overcoming data fragmentation and adopting a proactive approach to pair with traditional retrospective programs. To get started, explore the following action plan framework and key performance indicators (KPIs) to make the most out of your risk adjustment program.

Foundational elements for a risk adjustment action plan

There are three crucial elements from which to build an integrated risk adjustment program: mastering change, strengthening compliance, and leveraging technology.

• Mastering changes. Mastering regulatory changes is critical to financial and compliance success. The CMS-HCC Model V28 implementation, the increasing regulatory scrutiny of high-risk conditions and in-home health assessments, and others—these are not isolated events but coordinated reform. Organizations that can’t adapt to or face these compliance risks are unlikely to be successful in the long term.

•  Strengthening compliance frameworks. Building a strong compliance framework is essential to improving data accuracy and reducing compliance risk. Include new tools like second-level review, implement regular inter-rater reliability (IRR) testing, design targeted education based on error patterns—these proactive compliance investments will help anticipate potential issues and maintain program credibility.

• Leveraging technology and analytics best practices. New capabilities available to health plans, such as predictive analytics, support at the point of care, and EHR integrations, help improve risk data capture while reducing administrative burden for health plans and providers.

Rolling out an action plan framework and timeline

With these three elements underway, health plans should next consider timing. Creating a better risk adjustment program requires planning for the short term and the long term. These are our recommendations on the next steps for building an action plan and driving execution.

What to accomplish in the next week:

• Review documentation for high-risk conditions. Conduct a forecast review of documentation practices related to high-risk conditions identified by OIG In resources such as this toolkit on decreasing improper MA payments through identifying high-risk codes and this report on inappropriate use of HRAs.

• Assess CMS-HCC Model V28 impact and confirm readiness. The transition to CMS-HCC Model V28 will be fully implemented in payment year 2026. The new model’s significant changes will lead to greater specificity in the modeling results, more detailed documentation, and exactness in coding. Complete a comprehensive readiness assessment, anticipating and addressing impact on your operations and documentation strategies.

• Launch coding team compliance updates. Initiate immediate coding team updates on compliance changes. Doing so helps to reduce learning curves, to ensure time for testing, and to achieve excellence faster.

In the next 90 days:

• Maintain a strong compliance framework. Deploy and implement a compliance framework, considering appropriate operational protocols. Be sure to include: Strong documentation alignment with providers; an enhanced coding team offering both technology support and advanced training with the latest industry and regulatory updates; and multi-layer quality assurance, including targeted audits, regular testing and timely interventions, and second-level reviews. 

• Review and update your technology plan. Assess the performance of your current data and technology capabilities, identifying any barriers to success and opportunities to improve. Collaborate with internal stakeholders to define priorities and timelines.

• Assess opportunities for improvement. Comb through your readiness plan to identify any unforeseen gaps. Prepare initiatives to improve the implementation and execution of new programs, leveraging industry best practices.

In the next year:

• Launch new capabilities. Implement key updates to your risk adjustment programs by integrating prospective, concurrent, and retrospective methodologies.

• Develop a support system. Put together provider support and alignment programs. This should include targeted provider training, regular audits and feedback systems, and incentive programs to promote engagement and collaboration 

• Establish a measurement system. Create a comprehensive year-over-year evaluation framework measuring KPIs across prospective, concurrent, and retrospective programs, to gain and share insights on opportunities, barriers, and overall performance.

All these changes help push toward a better risk adjustment model that captures real clinical complexity, supports appropriate payment, and ultimately leads to better care. Organizations that view this change as a transformation opportunity—not a compliance burden—will emerge stronger and more successful.

KPIs to track and improve impact

Implementing prospective and concurrent capabilities is only valuable if their impact is measurable, yet KPIs that work for traditional retrospective programs will not work in this integrated model. How can organizations measure success in this new prospective and concurrent world? Here are a few examples:

Organizations that can create comprehensive risk adjustment strategies are set up for success in the new year. As regulations and industry standards continue to grow faster, health plans need to keep up with a proactive, integrated approach. Setting up a solid plan and key KPIs can help your plan stay ahead.

Prepare your risk adjustment strategy for the new year. Interested in getting started? Start a conversation with one of our Cotiviti experts and see what the possibilities are.