The Affordable Care Act (ACA) healthcare market is growing steadily, with over 21 million people enrolled in an ACA Marketplace Plan in 2024 as more plans continue to enter the market. Health insurance issuers with risk adjustment covered plans participating in HHS-RADV reached 76.4% in 2022, compared to 71.3% in 2021, according to data from the Centers for Medicare & Medicaid Services (CMS).

As we expect this trend to continue due in-part to the impact of Medicaid redetermination,  a reliable risk adjustment program is necessary to capture member risk, secure appropriate risk-associated revenues, and improve care delivery and data.  

Recent HHS-RADV audits from CMS revealed several highly misdiagnosed HCCs, including diabetes with chronic complications and heart arrythmias. Health plans considering entering this market or expanding their current offerings can learn how to optimize the impact and compliance of their commercial risk adjustment programs to best serve their members.  

Read Cotiviti’s new commercial risk adjustment checklist for recommendations to: 

• Improve retrieval rates by collecting timely and complete data
• Minimize administrative expense
• Enhance accuracy of coding results to address annual audits 

Dive into our recommendations and lessons learned from over 25 years in the risk adjustment space. Cotiviti’s expertise has led to consistent high-quality results, including >98% coding accuracy across our commercial risk adjustment clients in 2023.

Don’t miss this opportunity to improve your commercial risk adjustment program and prepare for the year ahead.