3 key risk adjustment strategies to drive success in 2024

Innovation, quality, efficiency are the key to success amid evolving regulations and technologies in risk adjustment for Medicare Advantage (MA) plans. Capturing complete records in a timely manner while minimizing provider abrasion is a complex and sophisticated process that requires a scalable, refined approach. Here are three risk adjustment strategies to consider in 2024 to drive better results.

Improving risk adjustment coding

The financial implications of having to return overpayments from the Centers for Medicare & Medicaid Services (CMS) underscore the importance of proactively improving risk adjustment coding quality. As RADV and Office of Inspector General (OIG) audits persist, payers must allocate resources to mitigate potential financial losses. Working closely with finance teams to plan for potential overpayments allows organizations to prepare for the impact, ensuring financial stability in the face of audits and regulatory scrutiny.

Prioritizing quality is essential for risk adjustment coding practices. Payers should continue to invest in ongoing training for coding teams to ensure proficiency in coding guidelines and model changes. By staying abreast of regulatory updates and industry best practices, organizations can maintain compliance and enhance coding accuracy.

In addition, assessing coder accuracy and provider performance practices enables continuous improvement and optimization of risk adjustment processes. Leveraging industry experts for additional review or exploring hybrid approaches can provide valuable insights and inform organizational strategies for risk adjustment success each season.

A new valuable tool is the OIG's toolkit released last year, intended to help MA plans improve the accuracy of their submitted diagnoses. Instead of building and creating logic from scratch, plans can use SQL code directly from the toolkit to identify error-prone diagnoses. Plans can use this code as a baseline and then determine whether there are other combinations to layer on top of this base logic to identify suspicious coding patterns.

Meeting providers where they are for record retrieval

High-performing medical record retrieval and industry best practices include data management, outreach tactics, and metrics.

Normalizing and enriching data is paramount in ensuring data accuracy and eliminating duplicates. Aggregating data from various EMR systems often results in duplicate data elements, emphasizing the importance of data normalization. For instance, discrepancies in medication lists due to different documentation practices highlights the need for standardized data enrichment processes. By addressing these challenges, plans can help ensure that retrieved data is accurate, consistent, and actionable, driving better outcomes in risk adjustment efforts.

As technology advances, the shift toward digital retrieval methods is gaining momentum. While traditional methods like on-site visits, copy services, fax, and phone outreach remain crucial, integrating digital solutions can significantly enhance efficiency. Understanding provider site mapping algorithms allows payers to tailor approaches, optimizing retrieval methods for each provider site. Understanding the provider’s preferences, such as preferred method of contact, and saving them for future reference improves retrieval outcomes. By meeting providers where they are, health plans can minimize administrative burdens and streamline processes, ultimately improving data accessibility.

Finally, creating an "activation plan" that delegates retrieval responsibilities to a dedicated task force can alleviate internal strain and streamline the data retrieval process.

Implementing interoperability to drive impact

To effectively navigate the evolving regulatory landscape, it’s important for health plans to define organizational priorities and conduct a comprehensive assessment of their infrastructure, markets, and technologies. This evaluation is essential for establishing both legislative compliance and technical proficiency in data retrieval processes.

Selecting the appropriate data partners is crucial to achieving accurate and timely data retrieval. It's imperative to ensure that your data retrieval partners are in sync with your organization's markets and business model. When establishing partnerships, carefully consider the requirements for building connections, maintaining APIs and interfaces, and managing data storage.