Here are three ways to increase premium accuracy, close gaps in care, improve the member experience, and increase member retention.

Between 2021 and 2022, total enrollment in Medicare Advantage (MA) plans grew by more than 9 percent as seniors aged into Medicare eligibility or transferred into MA from traditional Medicare. While achieving new member growth is a positive development for any MA plan, it also carries complications: based on Cotiviti’s analysis, the average risk adjustment factor (RAF) score for new MA enrollees is 30–40 percent lower than fully risk-adjusted plan members due to limited member history and gaps in care analytics, which also negatively impacts Star ratings measure outcomes and bonuses.

Here are three strategies that can help not only increase premium accuracy, but close gaps in care, improve the member experience, and increase member retention.

Meet new members where they are

MA plans that take a multi-channel approach to engaging with their new members will see the most success. This includes tactics such as:

  • Conduct a multi-faceted telephonic health risk assessment (HRA) within the first 90 days of membership to better understand care needs and history, pushing findings to risk adjustment, quality, and care management programs
  • Promote digital health management apps
  • Assist with primary care physician (PCP) appointment scheduling
  • Launch care opportunities with in-home health assessments

A multi-channel engagement approach will help MA plans fill in data gaps to build robust member profiles, which support segmentation and stratification for care management programs. It also enables members to forge valuable connections with both their PCP and their health plan to reduce gaps in care and uncover any challenges the member may face related to social determinants of health (SDoH) that have not been readily captured in their claims history such as housing, transportation, and food insecurity.

Invest in intelligent member analytics

After collecting information through telephonic and in-home assessments, as well as analyzing the member’s previous RAF score for those members switching plans, MA plans must act on this valuable data to ensure they meet members’ care needs. Plans should invest in prescriptive analytics to determine what the next best action is for a member based on which tailored intervention will achieve the greatest likelihood of success.

This can take the form of both clinical and nonclinical interventions. For example, for members facing SDoH issues, this may be a nontraditional intervention such as paying for members to take a Lyft to get to their next PCP appointment or connecting them with a food bank to make sure they have their most urgent nutritional needs met.

Plans must also take advantage of every touchpoint to encourage members to close care gaps. This could mean that when a member calls into member services, the agent has the member’s care gap history right at their fingertips and can conduct a warm transfer to the care management team to help schedule a PCP or specialist appointment.

Improve documentation completeness and coding accuracy

When welcoming new members into the plan, it’s essential to obtain adequate documentation so you can recapture any hierarchical condition categories (HCCs) of chronic non-resolved conditions is paramount. New members’ health status must be accurately assessed, recorded, and documented in medical records, bills and in claims and encounter data. This requires a significant investment in educating both provider networks and internal coding teams to ensure all documentation and coding complies with clinical coding reporting requirements.

This is especially true as government scrutiny of in-home assessments continues to rise amid Office of Inspector General concerns. With the help of analytics oversight, health plans can not only find missed coding opportunities and incomplete care plans but also uncover unsupported codes that they must delete to maintain strict compliance.

Keeping it member-centric

Managing a surge of enrollees can be both an exciting and daunting task for MA plans. To maximize success, plans must ask themselves, “How will this action or investment impact our members’ care and satisfaction?” Ultimately, they will find that what’s best for the member is also best for the organization. By capitalizing on opportunities to improve premium accuracy, MA plans will also be able to offer better benefits, experience, and outcomes to the seniors who rely on them for their health care.

About the author

As executive vice president of operations for population health management, risk adjustment, and quality, RaeAnn Grossman is responsible for leadership and management oversight of financial performance and operations, as well as innovation, vision, strategic and business planning. In this capacity, she is reframing and accelerating the success and impact of Cotiviti’s industry-leading risk adjustment, quality and stars, network and clinical analytics, and consumer engagement solutions focused on health plan success, health equity and outcomes, and provider performance. With her extensive track record of customer focus, value creation, along with government program and industry experience, Grossman drives the Cotiviti portfolio to improve financial and clinical metrics, reduce the cost of care, and create a landscape for health equity.