Value-Based Care is Here to Stay: Key Strategies for Developing a Risk Adjustment Program

In part 1 of our Value-Based Care is Here to Stay blog posts, we discussed the importance of risk adjustment to a provider’s success in value-based care. Implementing an effective risk capture program, however, is not an easy feat, and requires providers to transform how their organizations operate and develop the knowledge, infrastructure, and resources to be successful.

Many providers don’t know where to begin, but often believe that an EHR-integrated solution to deliver gaps at the point-of-care is the silver bullet to achieving accurate risk capture. However, simply implementing a tool for physicians to use is rarely successful without support from the appropriate people, processes, and technology. Overcoming these hurdles requires combining process engineering with technology-enabled solutions and a well-formulated change management strategy. To break down the components of a successful risk capture program, we’ve developed a comprehensive, encounter-centric framework to set the stage for continuous improvement efforts:



Addressing each of these encounter phases is critical to developing a successful risk capture program. Providers are at various stages of reaching this level of maturity and cannot be expected to make all these changes overnight. We recommend a phased implementation approach. This will allow organizations to establish early wins, develop sustainable processes, and maintain effective risk capture as they scale.

For providers new to risk adjustment, starting with a post-encounter coding review often provides the highest immediate ROI because it enables risk capture from diagnoses that have already been documented, but not coded, without requiring physician workflow modification. By using technology and bringing the retrospective review more upstream for a concurrent workflow, providers can ensure that claims accurately reflect the care provided and diagnoses are adequately substantiated before they go out the door. In addition, concurrent review generates a more complete and accurate patient acuity baseline to fuel subsequent prospective gap identification and physician engagement efforts.

Prior to putting any information in front of physicians, there is an opportunity to leverage analytics on historical patient data to identify prospective risk capture gaps pre-encounter. Providers can identify gaps such as patients with suspected conditions who lack the proper documentation to be submitted for reimbursement. Advanced analytics technology can also ensure that only the most accurate intelligence is being put in front of a physician at the point-of-care to increase trust of the providers and reduce any potential for physician abrasion. Furthermore, risk adjustment is a new concept to many physicians and staff. Providing sufficient education on documentation and coding guidelines will help enable all members of the care team to contribute to risk capture.

During encounter with a patient, a point-of-care solution can deliver the gaps to the physician and allow the closure of gaps without departure from the physician’s EHR-centered workflow. A successful point-of-care solution must also facilitate the documentation of outstanding risk conditions through accurate and complete encounter documentation in the EHR. This allows providers to efficiently capture the risk of their populations, decrease the need for follow-up visits, and streamline coding review processes.

This encounter-centric framework and phased implementation approach allows organizations to develop a plan for continuous improvement and transformation. As providers begin participating in risk-sharing arrangements, starting with a retrospective review process allows them to close risk capture gaps and assess patient acuity. Once an organization has developed a more mature risk adjustment infrastructure, it can then layer in additional technology and analytics solutions to identify gaps prospectively, and optimize their risk capture at the point-of-care.

Click here to learn more about how providers can leverage technology and a strategic approach to achieve success in value-based care.