Checklist: Creating a comprehensive risk adjustment program for the new year

Health plans today face mounting pressure to modernize their risk adjustment strategies. With regulatory oversight intensifying and technology unlocking new possibilities, organizations must move beyond traditional methods and embrace a more proactive, integrated approach to stay ahead.

As precision becomes the new norm with updates like CMS-HCC Model V28 and the increased scrutiny of health risk assessments (HRAs), the healthcare continuum inches closer to real-time data capture. As such, digital transformation and AI are bringing risk adjustment closer to the point of care. These advances reduce administrative workload and improve data quality, but they also demand thoughtful planning and execution. Consider an action plan as healthcare organizations continue to navigate the new reality of risk adjustment.

Creating a risk adjustment plan for the future

As the first step to creating a risk strategy, health plans should focus three foundational pillars:

• Mastering change: Regulatory reforms are not isolated events. Set up dedicated processes to monitor and adapt quickly and effectively to ongoing changes.
• Strengthening compliance: Build a robust compliance framework with dedicated tools including targeted education and inter-rater reliability (IRR) testing. Proactive compliance investments help anticipate challenges and maintain program credibility.
• Leveraging technology: Evaluate the potential of new predictive analytics, point-of-care support, and EHR integrations to streamline risk data capture and reduce administrative burden.

A successful risk adjustment program requires both immediate and long-term planning, creating a scalable approach with objectives for the present as well as the next year and beyond.

In the short term, plans might consider reviewing documentation, assessing readiness for CMS-HCC Model V28, and updating coding teams on compliance. In the long term, considering how to integrate new capabilities and support providers will be key, and plans will have to think about how to enable continuous improvement. Setting new KPIs that go beyond traditional retrospective programs will also become critical to improve impact.

Dive deeper into risk adjustment transformation

Consider regulatory changes as opportunities for transformation: Health plans can build risk adjustment programs that reflect true clinical complexity, support appropriate payment, and ultimately improve patient care. Organizations that adapt and innovate will be best positioned for long-term success.