The Affordable Care Act (ACA) health care 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 Risk Adjustment Data Validation (RADV) reached 76.4 percent in 2022, compared to 71.3 percent in 2021, according to data from the Center 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.
Here are five best practices to consider for more successful commercial risk adjustment results.
Confirm plan data for accuracy: Many plans struggle with data reconciliation from one department to another, and these challenges are compounded by the sheer number of departments in a health plan that contribute to the data flow in a risk adjustment program. Conducting an assurance review of plan data on EDGE prior to the submission year will reduce data inconsistencies and ensure data and member accuracy. The team overseeing the submissions process should have deep, cross-functional expertise and broad knowledge of the entire process to identify leakage and resolve issues that can occur at any point. In addition, monthly stakeholder meetings with finance, claims processing, underwriting, and risk adjustment operations will help align all departments to a similar goal.
Understand your members: What conditions will you need to anticipate and care for? Which members have the highest risk? Which engagement methods do they respond to? Suspect analytics can help organizations better identify, prioritize, and reach members with the highest probability of having undocumented conditions. An informed, prioritized list of patients, in turn, helps drive your strategy to retrospectively find and document conditions for consideration in your risk-adjusted payment formula. Suspect analytics will also help you avoid chasing members carrying less risk. The ideal time to start suspecting is November and December, as you can review as many claims as possible and still have enough time to find conditions for the current submission year.
Retrieve medical records efficiently: The most certain way to validate and document potential conditions is through a patient’s medical record. In many cases, a provider may note the existence of a condition in a patient’s chart but not bill for anything specific to that condition in the claim. For example, if a patient is seen for a routine well visit, the doctor may note that the patient suffers from diabetes. However, because the patient is not being seen or treated for diabetes during that visit, the provider does not submit any claim detail regarding the condition. The actual record, however, can be used as documentation.
When retrieving medical records from provider offices, minimize provider abrasion and unnecessary effort by streamlining your approach. Leverage digital data retrieval, consolidate multiple member chart requests across offices and lines of business, track all office staff details and prior requests, and index paper records for audit purposes. Begin retrieval once your suspecting efforts are complete, ideally in December.
Code accurately and capture all relevant data: Accurate and complete coding should be your seasonal risk adjustment mantra. Be sure to capture all diagnosis and HCC data when coding. The accuracy rate is important—even a slight variation, when extrapolated across an entire population, can make a significant difference in revenue and impact HHS RADV audit results. Work with your team of coders to improve accuracy or take advantage of a vendor’s expertise in this area. Coding activities typically start around January and February and continue right up until the final deadline. To maintain a high accuracy rate, independently audit both coders and vendors to ensure effective quality improvement processes are in place.
Compile, scrub, and triple-check your data: It’s critical to quality-check your coding data for accuracy. Conduct multiple quality assurance reviews and audits throughout the process to ensure the highest level of quality and accuracy prior to submission to CMS. Partnering with an expert vendor, health plans can strengthen independent overview and improve accuracy to respond to increased compliance scrutiny and best prepare for annual audits. The submission of accurate baseline data creates a solid foundation for understanding your acceptance rate and submission goals. The quantity and quality measurements that CMS uses to evaluate submissions are very important in tracking and understanding your members’ utilization year over year.
By following these steps, commercial health plans can create a more sustainable risk adjustment program while having more confidence in their results. For more information, read Cotiviti’s 10 tips for a successful commercial risk adjustment program.
About the author
Katie Sender, MSN, RN, PHN, CRC, is Cotiviti’s vice president of clinical and coding services. With over 25 years of health care experience, Sender is responsible for leadership and management oversight of teams spanning the globe to ensure optimal client outcomes and service delivery through management of key performance indicators related to clinical and coding solutions.