Modernize Your Risk Adjustment Program

Three Keys to Advance Overall Performance

Whitehurst Health Fidelity Risk Adjustment Program

With the industry shifting toward value-based care and payment models, there is an increasing need for health plans to continually improve their risk adjustment program(s). As plans seek to modernize their risk adjustment operations, there are a few unique challenges and considerations to bear in mind.

1. Data Acquisition and Analytics

Are your risk adjustment analytics informed by all possible sources of data? Health plans should begin their efforts by assessing the types of data that are available. This likely includes administrative data: inpatient and outpatient medical claims, as well as pharmacy and laboratory claims. However, the lion’s share of patient data – an estimated 80 percent – lies in unstructured text in clinical charts, and plans need to develop strategies to access such data. New technologies provide ways to acquire and analyze chart data, and analytics can help to identify charts that are most likely to have risk conditions to ensure maximum ROI on charts that are retrieved.

Key Considerations:

  • Where does chart data reside, especially for chronic conditions that may be under-coded on claims?

  • Are network providers willing to share electronic health record (EHR) data?

  • What technology solutions can be used to facilitate acquisition of data, both electronic and paper-based?

  • What technology solutions can be used to extract valuable information from unstructured chart data?

2. Introducing Automation

The majority of today’s retrospective risk adjustment programs are conducted by trained coders via manual processes. However, these manual methods will fail to keep pace with growing membership under value-based arrangements without a commensurate increase in headcount or outsourced services. Instead, health plans should invest in tools that streamline the risk adjustment process, while reducing human error and audit risk. Technology-enabled solutions can help to automate much of the manual processes, enabling plans to expand their risk adjustment programs without expanding staff. In addition, technology will be help plans to analyze larger sets of data to gain more accurate snapshots of risk adjustment coding opportunities within their populations.

Key Considerations:

  • What resources are currently spent on retrospective coding efforts, both in-house and outsourced?

  • To what extent are your coders focusing their attention on the highest priority charts where HCCs are likely to be found?

  • What technology investments can reduce coding burden and improve payment accuracy?

3. Provider Incentives

A key part of any risk adjustment program is ensuring that providers follow best practices related to optimally capturing risk. Across all providers in your network, there are bound to be differences in membership profiles, coding accuracy on claims, level of success in confirming suspected conditions, ability to share patient data, and many other factors. Health plans must be equipped with the analytics necessary to gauge provider performance and create the most appropriate incentives to improve performance where needed. Such analytics can also inform a broader array of applications, such as bid rate calculation and network contracting.

Key Considerations:

  • How can you incent providers to grant access to their patient records in a timely and consistent manner?

  • How can you incent providers to treat and accurately document potential gaps in care?

  • How can you identify specific providers in need of coding education or training?


It’s important to remember that risk adjustment isn’t just about payment accuracy. A successful risk adjustment program will also help further the mission of the health plan – keeping patients healthy and preventing chronic health issues. As you look to modernize your risk adjustment programs, consider how to make use of all possible sources of data, automate resource-intensive coding efforts, and ensure provider adherence to best practices.

For more information on risk adjustment programs, please contact us.