Jessica Smith

Risk Adjustment Importance During Open Enrollment

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Now is the time of year when everyone is preparing for back-to-school events and the upcoming holidays, but in that mix is the ever-so-important…Medicare Open Enrollment. Medicare Open Enrollment is an important time to keep or lose valuable members who may have been long-time participants or new to the plan in the last year. There are many reasons member retention is important, but one that is not often talked about it risk adjustment. Risk adjustment has many different types of models utilized to calculate a member’s risk score. The more consistent information you have about a member, the more accurate risk score can be calculated and will allow for an easier understanding of member gaps in care.

Having long-term members allows a health plan to get to know their members and customize care connections needed to help in management of many chronic conditions. Knowing and understanding your member population is one of the most important pieces of risk adjustment. Although gaining new membership is important, the knowledge gap of that member exists due to the lack of history obtained. A new enrollee for risk adjustment purposes is a member who has less than 12 months of Medicare Part B in the data collection year. You want to build the knowledge of that member through medical encounters and analytics and reduce the amount of turnover in your population. When members have a new enrollee status, it makes predictive modeling and accrual calculations challenging to complete.

Although a member might be new to your health plan, they may have had another Medicare Advantage (MA) plan prior to enrolling with your organization. In an effort to assist health plans with the knowledge gap that exists when members change MA plans, the Centers for Medicare & Medicaid Services (CMS) released a memo on June 20, 2017, that addresses the issue when a member is enrolled in a plan with a different parent organization during the data collection period than in the payment year. CMS acknowledges the challenges of new enrollee knowledge gaps that impact the diagnosis information captured. In order to ease this challenge, CMS is specifying organizations are able to submit diagnosis codes to Risk Adjustment Processing System (RAPS) for years when a member was enrolled in a plan with a different parent organization but not if the member was in Fee-for-Service Medicare in the prior year.

Regardless of the longevity of the member’s tenure, the ability to submit the information to CMS through RAPS and Encounter Data System (EDS) is imperative. Internal controls and validation best practices should be built to maintain the quality of care for the member and continued success of the plan in which they are enrolled. Important characteristics of a risk adjustment program include:

  • Understanding of internal information and members
  • Strong analytics
  • Program strategy and focus
  • Pre-submission validations
  • Data submission reconciliation of errors and comparison of results

For additional questions and inquiries about how GHG can support your organization’s risk adjustment programs, please contact me directly at



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Jessica Smith

About 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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