Are you operating under a false sense of security for your risk adjustment program?

Risk adjustment at its highest form is nothing more than a calculation. The unique processes surrounding the operations to ensure accuracy of the calculation can be complex. The processes developed and utilized throughout most organizations are relatively similar, however, they are often times misaligned in their approach to operationalize these processes, in turn adding little value or even increasing audit risk. Good strategy and planning with poor execution and oversight lead to an inaccurate risk score calculation overall.

Some organizations receive a false sense of security around their risk adjustment program when vendors or business process outsourcing is utilized. Risk adjustment is not a standalone process that can run as a silo within a vendor solution. It requires an army of different expertise, and the use of vendors in some capacity is needed, but an organization needs to be heavily involved in all processes to ensure accuracy of the information impacting the risk adjustment calculation.

Even the greatest, most refined organizations with robust staffing and thoughtful strategic planning sometimes fall short in reflecting risk accurately. Risk adjustment requires balance throughout the program to truly be successful. Integrating risk adjustment expertise throughout the organization is crucial to achieving this needed balance.

If you feel this is a good representation of risk adjustment operations at your organization, here are a few tips to consider as you prioritize next steps to remedy any issues:

  • Understand and implement the latest regulations and guidance. The Centers for Medicare & Medicaid Services (CMS), the Department of Health & Human Services (HHS), and state Medicaid programs provide periodic updates and webinars regarding requirements for risk adjustment. Be sure to stay up to date with what the new requirements are and that appropriate steps are being taken internally to stay in compliance with all regulations.
  • Measure all interventions. You have gone through the effort to establish interventions to ensure risk score accuracy – make sure the efforts are contributing in a meaningful way. Whether it is a retrospective, prospective, or combined outreach with another department, be sure you are able to evaluate the performance of each intervention to determine its effectiveness.
  • Validate, validate, validate. The basis of this is to make sure your organization has done its proper due diligence and validation on the data prior to sending it to CMS, HHS, or the state. Ultimately, this is the information you will be audited against, so validations go a long way to reducing risk during an audit.
  • Think outside the box. Over the years, the risk adjustment program has led people to believe only certain processes are a part of the program when, in all reality, the possibilities are endless when it comes to risk adjustment operations, so think outside the box for new, innovative ideas.

There isn’t a single solution to risk adjustment, rather it’s a combination of old practices with new innovative practices to develop a program that works best for your organization.

For assistance with evaluating your risk adjustment program, please contact me directly at




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Jessica Smith
Jessica Smith

Jessica Smith is Vice President of Healthcare Analytics & Risk Adjustment Solutions at Gorman Health Group (GHG). In this role, she is responsible for the execution and oversight of risk adjustment consulting services for managed care, provider practice, and commercial market clients, and leading and integrating cross-functional teams to ensure superior performance outcomes related to risk adjustment operations. Read more

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