The Secret Sauce of Risk Adjustment: Implementation, Implementation, Implementation

As we are coming close to year end, we have all learned a great deal. The number one thing we hear from health plans: “I thought they could implement.” 
Risk adjustment is successful only if you couple speed with quality.  The three most constant stumbling points for member evaluations programs are

 1) compilation of data
2) suspect list generation
3) provider recruitment

As you talk with your health plan and medical group peers, their references and experience should help you navigate this treacherous path.

The questions you may need to ask:

1. How long does it take you to compile and refresh data?  Best in class answer: 10 days to compile a health plan or medical group’s data and 1-2 days to refresh it monthly.
2. How long should it take to generate a member suspect list?  Best in class answer: 5-10 business days
3. How long does it take you to recruit or train or allocate member evaluation providers?  Best in class answer: Within 20 days of contract execution, your assessment vendor needs to have their evaluators recruited, trained, and in the field with your members.

Make sure you ask the right questions and pick the right partners.  If you selected a turtle this year, you better start looking for a rabbit for 2012. Slow and stumbling does not win the race and you have to win the risk adjustment race to stay alive.

1 Comment
  1. You are correct — Implementation is the key and it seems straight forward. Why do so many still have issues?

    good article!


Leave a Reply

Your email address will not be published.