Evaluating effectiveness of your organization against best practices for risk adjustment and quality programs

Whether it’s to reduce medical loss ratios or improve competitive positioning with more affordable products, health plans are under increasing pressure to reduce medical expenses through population health management. Where do you start when it’s difficult to identify and prioritize areas of opportunity that will have the greatest impact?

A critical first step is to assess where your organization is now:

  • Is your organizational structure optimal for efficient execution?
  • Is the right analytic infrastructure in place to help guide decisions?
  • Are all of the right programs in place to improve quality results and compliance?

Examining your strategic framework is a critical first step. Identify programs you’d like to focus on, balanced against those already in place as part of your operational functionalities, such as care management and pharmacy management. Consider whether the ROI for any new programs will justify your expense in terms of human capital and allocated dollars.

Designing an integrated risk adjustment program

In addition to looking outside your program for other influences that may impact program strategy and execution, your risk adjustment program should include five components:

  1. Understand your population and their history. Prioritize members to engage, focusing on those who can have an impact on your program to better understand opportunities for risk adjustment.
  2. Perhaps the most strategic area of your risk adjustment program, this will help you determine which programs will best meet your member and provider profiles. More than likely, you will need several different programs to effectively do this.
  3. The actual execution of your programs. Deploying activities can close specific coding gaps and improve overall quality.
  4. Submission processes allow you to collect, report and submit data to CMS to get the benefit of the risk adjustment programs you’ve implemented.
  5. Integrated active compliance tracking and monitoring throughout the entire program is essential.

For an in-depth discussion on how you can perform a full assessment of both risk adjustment and quality based processes, procedures and staffing compared to industry best practices, listen to our on-demand webinar, “Evaluating effectiveness of your organization against best practices for risk adjustment and quality programs.”

About the authors

Mary Larson

Risk Adjustment Lead,
Network and Population Health Consulting

Mary LarsonMary Larson is the Risk Adjustment Lead within Network and Population Health Consulting for Optum. She has over 10 years of experience improving health plan revenues with specific focus on Medicare and Medicaid Risk Adjustment.

Mary has experience in healthcare operations leadership, strategy development, process and system re-engineering, large client and vendor implementations, data management, organizational redesign, technology development, and compliance. She specializes in bringing together large, matrix teams to solve complex strategic and operational challenges.

Some examples of her recent work include providing management oversight of Optum’s Prospective Risk Adjustment business, leading the Risk Adjustment strategy development and tactical planning for a large regional MA health plan, and leading the development of a Risk Adjustment Submission system.

Ryan McKeown

Quality Lead,
Network and Population Health Consulting

RyaRyan_McKeownn McKeown leads the strategy and delivery of consulting offerings to develop, implement and drive successful integrated quality programs in the Medicare Advantage, Medicaid and Commercial/ACA space. Focus areas include: governance, strategy, financial/ROI, engagement programs, technology, data management and analytics across HEDIS, CAHPS, HOS, pharmacy and operations measures.

Prior to joining Optum, Ryan served as the Medicare Strategic Programs Manager at Martin’s Point Health care. Ryan was responsible for identification, development and implementation of strategic programs to improve Medicare Advantage star ratings and enterprise health plan quality initiatives. Ryan led the data analytics and reporting, vendor management, external provider partnerships, internal project teams and as organizational stars champion communicated strategy and results to both executive leadership and the board of directors.



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