Laying the foundation for commercial risk adjustment success amid COVID-19

The core of a successful risk adjustment program is fully understanding your members as well as the various data exchanges that take place along the risk adjustment continuum. But the COVID-19 pandemic has introduced new challenges to optimizing risk adjustment revenues while maintaining compliance. Read this checklist for our suggested tactics.

Stay up to date on regulatory and maintenance changes—and understand the impact.

REGTAP provides advance maintenance notices to help inform plans on what they should do to prepare for an upcoming risk adjustment program. Knowing what to expect and how best to prepare will position your plan favorably. A vendor that continually monitors and interprets the latest payment model updates can alleviate the burden of combing through notices yourself and will offer the expertise to help you plan your risk adjustment strategy.

Confirm plan data for accuracy.

Many plans struggle with data reconciliation from one department to another, and these challenges are compounded by the sheer number of departments in a health plan that contribute to the data flow in a risk adjustment program. Conducting an assurance review of plan data on EDGE prior to the submission year will reduce data inconsistencies and ensure data and member accuracy. The team overseeing the submissions process should have deep, cross-functional expertise and broad knowledge of the entire process to identify leakage and resolve issues that can occur at any point. In addition, monthly stakeholder meetings with finance, claims processing, underwriting, and risk adjustment operations will help align all departments to a similar goal.

Conduct outreach early to minimize administrative expense.

Encourage members to visit their primary care providers, and educate providers on commercial risk adjustment as well as recommendations for members who are disengaged from their wellness plan. Ensuring that members visit their providers annually allows issuers to view their health in detail early in the year, including their HCC and non-HCC conditions, HEDIS® review measures, and disease and case management cues. This, in turn, helps identify members who should be enrolled in health and wellness programs. Targeting members for in-home assessments is usually a secondary response, but for the 2020 benefit year, providers will be utilizing telehealth services due to the COVID-19 limitations. After COVID-19 restrictions are lifted, many provider offices will also be overwhelmed and limited in resources. Telehealth and in-home assessments can help providers assess the wellness of their members and close condition gaps.

For more best practices based on Cotiviti's experience working with managed care organizations across their risk adjustment initiatives, download our newly updated checklist offering 10 tips for a seamless commercial risk adjustment program.

Read the checklist

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).


Rebecca Darnall
As product director, Rebecca provides leadership and oversight into new product and business development, growth, and strategy to assist health plans in the optimization of revenue and risk mitigation. With more than 15 years of healthcare experience, she has a strong track record in creating and establishing operating policies and procedures for risk adjustment programs that comply with CMS requirements and industry practices.

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