How to Ensure a Member’s Risk Score Is Complete

In football, you need a strong offensive line to protect your quarterback and make room for your skill players to operate. These individuals need to work together as a team within a team. They are the core of any successful football team. As my friend, the coach, likes to point out, the only time they ever get their name in the paper is when they’ve made a mistake. And, on any given play, all it takes is for one of these individuals to miss a step, miss an assignment, or get outplayed for the whole line and play to break down.

In risk adjustment, we have a stream of data that must flow uninterrupted through multiple points, and if at any point there is a mistake, then our risk adjustment play will break down. Each of these touch points are nodes within our system through which a member’s information must pass, and any mistake, as little as a typo, can cause havoc.

Let’s think about this at a member level. Imagine there is a member of your health plan who has diabetes and congestive heart failure. For the Centers for Medicare & Medicaid Services (CMS) to receive all that member’s info so her risk score is complete and accurate, multiple things must occur.

  1. She must go see her provider.
  2. Her provider must assess all her conditions and record them properly in her medical chart.
  3. The information from her chart must get accurately entered into the claims system and successfully submitted to and accepted by the health plan.
  4. The health plan must process the claims data into RAPS and EDPS formats and successfully submit them to CMS.

These five nodes in the system are your offensive line for risk adjustment. It just takes one of these nodes in the system to make a mistake, and the risk adjustment process will have problems. And, these steps must happen every year for each member. Health plans  need to have a strategy in place to support each of these links in the line of protection.

Again, the first step is for the member to see his or her provider. There are a few different strategies we can employ to try and engage our member and entice him or her to visit his or her provider.

Plan design is the first and possibly the most important step in getting your members to visit their providers. For example, do you have a $0 or low primary care physician (PCP) copay? Do you offer a transportation benefit? When you are making decisions about your plan designs for the next plan year, you need to consider how this will affect your members. If you can have your members show up on their own, without any additional plan intervention, then that is the most cost-effective type of member engagement. Remember, we want our members to visit their PCP.

One reality of the healthcare business, every business really, is limited resources and time. Member outreach is an important element that will get your members to see their providers. But you can’t always engage with everyone. Analytics play a key role in identifying which members are most at risk and need to visit their provider so you can target your outreach efforts.

Finally, if you can’t get the patient to the provider, bring the provider to the patient. Home health visits for your members who are not able to see their provider at the provider office can be invaluable. Another trend I’ve seen is health plans opening community clinics. This is making providers more accessible to members.

Your goal as a football coach, I mean Medicare Advantage plan, should be to have every member visit his or her PCP at least once a year. It is the only way for our member risk scores to be complete and accurate. I’ve mentioned a few strategies; there are others. Facilitating member PCP visits is one of the most important steps in protecting the quarterback. If your organization would like to discuss how Gorman Health Group can assist you with all phases of your risk adjustment game plan so that you can have a winning record, please contact us here.


Kirk Shanks
Kirk Shanks

Kirk Shanks is a Senior Consultant at GHG. He has a strong actuarial background with a passion for risk adjustment. Kirk’s primary expertise resides around data management, mathematics, and computer programming.

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